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Adult Intake Form

Contact Information

Birthday
Sex at Birth

Insurance Information

Insurance Type
Policy Holder's Date of Birth
Do you have secondary insurance?
Yes
No
Secondary Insurance Type
Secondary Insurance Policy Holder's Date of Birth

Therapy Questionaire

Are you currently in therapy?
Yes
No
Have you been in therapy before?
Yes
No
Most Recent Time in Therapy
Have you had any previous hospitalizations for mental health or substance use concerns?
Yes
No
Are you currently taking psychiatric medications for:
Are you currently facing legal action(s)?
Yes
No
If you would like to request a specific counselor, please indicate below.
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