Therapy
Individual
Couples
Family
Group
Anxiety Clinic
Behavior Medicine
(i.e., pain, chronic illness)
Assessment
Career
Academic
Personality
Other
How did you hear about us?
Insurance status*
Private
VCC
MCV code
Medicare/Medicaid
None
Military Service
Combat Veteran?*
Yes
No
Service history (check all that apply)*
Current active duty
Former active duty
Current Reserves/National Guard
Former Reserves/National Guard
None
Branch of service (check all that apply)*
Army
Navy
Air Force
Marines
Coast Guard
Not applicable
Personal information
Date of birth* (mm/dd/yyyy)
Age*
Gender*
Sexual orientation*
Ethnicity*
Marital status *
With whom do you live?*
Work status (check one)*
Unemployed
Employed full-time
Employed part-time
Student
Disabled
Other
Occupation*
Total family income
(before taxes)*
/year
Medical information
Have you had any serious or chronic medical or physical problems?*
Yes
No
If yes, please describe.
Are you currently on any medication for this problem(s)?*
Yes
No
If yes, what type(s) and dosage(s):
Primary Care Medical Provider
Name
Phone number
History
What are some of the feelings/thoughts you are experiencing? Check all that apply.*
Anger
Depression
Anxiety/panic
Alcohol/drugs
Fears
Crying all the time
Acting out in school
Learning problems
Confusion
Relationship issues
Life adjustment/enhancement
Other
Not applicable
How long have you been feeling this way?*
In your own words, please describe briefly the problem(s) you are experiencing.*
Have you felt this way in the past?*
Yes
No
If yes, please describe.
Has anything happened recently or changed in your life that might be related to these feelings? Check all that apply.*
Nothing
Recent loss or death of close friend/family member
Change or loss in work or living situation
Other:
Have you feelingsd any recent changes in the amount of time
you sleep?*
No change
Sleep more
Sleep less
Have you feelingsd any recent changes in the amount of food
you eat?*
No change
Eat more
Eat less
Have you ever been in a drug or alcohol treatment program?*
Yes
No
If yes, when and what for?
Have you ever been hospitalized for psychological reasons (i.e. for depression)?*
Yes
No
If yes, for what reason? When did this occur?
Are you currently taking any medications for anxiety, depression, ADHD, etc.?*
Yes
No
If yes, please list names and dosages.
Have you ever been charged or convicted of a crime (misdemeanor or felony)?*
Yes
No
If yes, please explain:
How many alcoholic drinks do you have in a typical week?*
None
1-3
4-7
8-11
12-15
more than 15
Do you use any street drugs or medications prescribed for
someone else?*
Yes
No
Are you ever involved in physical fights with other people?*
Yes
No
Are you currently, or have you ever, been involved in the legal system?*
Yes
No
Has your family ever been involved with Child Protective Service?*
Yes
No
If you have children, have you ever lost custody of your children?*
Yes
No
Do not have children
Thank you for taking the time to fill out our application. An intake coordinator will be in touch with you soon to continue the processing of your application.
