Client Intake Form Name * First Name Last Name Name You Like To Be Called: Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Phone (alternate) (###) ### #### Email * Date of Birth: * Age: Preferred Pronouns: Send me emails about workshops Yes No Who are the significant relationships in your life? Employment Salary (optional) Religion or Spiritual Path Exercise (what, frequency, duration, attitude) Is your diet healthy? Please describe your use of alcohol and drugs: (how much, how often, in what context, others' comments) Medical History & Present Health: Primary Care Doctor: Psychiatrist: Medications: Current/past Psychiatric hospitalizations: Prior Treatment: How effective was it and why? Why are you coming for therapy at this time? * Please describe any thoughts of killing yourself or others: * Please list some possible goals: * How did you hear about my practice? Thank you for filling out the client intake form! By submitting this form I agree that I have filled out this information truthfully, and to the best of my ability.