Intake Questionnaire

Note: You may fill out the electronic form below or print the intake questionnaire and bring it in to your first appointment.

Today's Date *
Today's Date
Name *
Birth Date *
Birth Date
Sex Assigned at Birth *
Gender Identity *
Marital Status *
Check all that apply.
Employment Status *
Check all that apply.
Have you ever received counseling in the past? *
Ever received a formal psychological evaluation? *
Include both prescribed and over the counter, vitamins, herbs, etc.
beer, glass of wine, and/or shot
Have you used drugs in the past 5 years? *
Do you ever think about physically harming yourself or committing suicide? *
Do you currently experience these thoughts? *
Ever think about physically harming other people? *
Currently? *
Do you currently feel threatened or in danger of being physically or emotionally harmed by another person? *

**Although forms submitted digitally come directly to me, due to the nature of email, the complete confidentiality of forms submitted electronically can't be guaranteed.