Forms

INTAKE FORM  
OFFICE POLICIES  
TELEHEALTH INFORMED CONSENT  

INTAKE FORM

Please provide the following information and answer the questions below. The information you provide here is protected as confidential information. Please return this completed form, along with a photo of your driver's license, by emailing it to solsticemht@gmail.com

    Male
    • Male
    • Female
    *Please note: Email correspondence is not considered to be a confidential medium of communication.
    Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc.)?
    Are you currently taking any prescription medication?
    Please list:
    Have you ever been admitted to a hospital or treatment center for inpatient psychiatric treatment?
    Please list and provide dates:

    GENERAL HEALTH AND MENTAL HEALTH INFORMATION

    1. How would you rate your current physical health? (please circle)

    Please list any specific health problems you are currently experiencing:

    2. How would you rate your current sleeping habits? (please circle)

    Please list any specific sleep problems you are currently experiencing:

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

    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. How often do you drink alcohol?

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

    10. Are you currently in a romantic relationship/s?

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

    12. What brought you to therapy?

    FAMILY MENTAL HEALTH HISTORY:

    In the section below identify if there is a family history of any of the following. If yes, please indicate the family member’s relationship to you in the space provided (father, grandmother, uncle, etc.).

    Please Circle

    List Family Member

    Alcohol/Substance Abuse
    Anxiety
    Depression
    Domestic Violence
    Eating Disorders
    Obesity
    Obsessive Compulsive Behavior
    Schizophrenia
    Suicide Attempts
    Bipolar

    ADDITIONAL INFORMATION:

    1. Are you currently employed?

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

    3. What would you like to accomplish outof your time in therapy?

    4. Do you consider yourself financially stable?

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