Intake Form

Please provide the following information and answer the questions below. Please note: information you provide here is protected as confidential information.

Please fill out this form and return it before your first session.

Please enable JavaScript in your browser to complete this form.

Name *

First

Middle

Last

Name of parent/guardian (if under 18 years)

First

Middle

Last

Birth Date *

Age *

Gender *

Female
Male

Marital Status *

Never Married
Domestic Partnership
Married
Separated
Divorced
Widowed

Please list any children/age

Street Address *

City *

State *

Zip Code *

Home Phone

May we leave a message? *

Cell/Other Phone

May we leave a message? *

Email Address *

May we email you? *

Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc.)? *

Are you currently taking any prescription medication? *

Have you ever been prescribed psychiatric medication? *

GENERAL HEALTH AND MENTAL HEALTH INFORMATION

1. How would you rate your current physical health?

Poor
Unsatisfactory
Satisfactory
Good
Very good

Please list any specific health problems you are currently experiencing

2. How would you rate your current sleeping habits?

Poor
Unsatisfactory
Satisfactory
Good
Very good

Please list any specific sleep problems you are currently experiencing

3. How many times per week do you generally exercise?

What types of exercise to you participate in

4. Please list any difficulties you experience with your appetite or eating patterns.

5. Are you currently experiencing overwhelming sadness, grief or depression?

6. Are you currently experiencing anxiety, panic attacks or have any phobias?

7. Are you currently experiencing any chronic pain?

8. Do you drink alcohol more than once a week?

9. How often do you engage recreational drug use? *

Daily
Weekly
Monthly
Infrequently
Never

10. Are you currently in a romantic relationship?

On a scale of 1-10, how would you rate your relationship?

11. What significant life changes or stressful events have you experienced recently

FAMILY MENTAL HEALTH HISTORY

First Choice

Paragraph Text

Alcohol/Substance Abuse

List Family Member

Anxiety

List Family Member

Depression

List Family Member

Domestic Violence

List Family Member

Eating Disorders

List Family Member

Obesity

List Family Member

Obsessive Compulsive Behavior

List Family Member

Schizophrenia

List Family Member

Suicide Attempts

List Family Member

ADDITIONAL INFORMATION

1. Are you currently employed?

Do you enjoy your work? Is there anything stressful about your current work?

2. Do you consider yourself to be spiritual or religious?

3. What do you consider to be some of your strengths?

4. What do you consider to be some of your weakness?

5. What would you like to accomplish out of your time in therapy?

Limits of Confidentiality

you message? would

I agree to the above limits of confidentiality and understand their meanings and ramifications.

I agree to the above limits of confidentiality and understand their meanings and ramifications.

I agree to the above limits of confidentiality and understand their meanings and ramifications. (copy)

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Get In Touch!

Contact Details

You can reach out to us with our number and email.

Phone:

404-436-4597 404-772-5858

Email Address:

capcivic@att.net

Address:

New Black Wall Street Market 8109 Mall Parkway, Suite 112, Madam CJ WalkerStonecrest"," Georgia 30038

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