Intake Information Form - Step 1 of 3Name *FirstLastAddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeDate of BirthMartial StatusMarriedSingleDivorcedPertinent Family InformationCell PhoneOK to leave a message? (copy)YesNoHome PhoneOK to leave a message?YesNoOther PhoneOK to leave a message?YesNoEmail *Referred ByNextHave you ever had any mental health services in the past or are you currently receiving mental health care?Have you ever taken psychotropic medications? If so, are you currently taking any? What medications?How do you rate your current physical health?ExcellentVery GoodGoodSatisfactoryUnsatisfactoryPoorAre you experiencing any specific health difficulties at this time?How is your sleep?How many hours do you average per night?How active are you?What types of activities do you do?How often?NextAre you coming to counseling due to sadness, grief or depression?How long have you felt this way?Have you experience a loss recently?Are you coming to counseling for anxiety or panic attacks?Have you recently had any significant changes or stressful events in your life?What is your current employment statusEmployed Full-TimeEmployed Part-TimeSelf-EmployedUnemployeedContractDo you enjoy your work? What are the significant stressors associated with your work?What are some of your strengths? What do you hope to gain from this counseling experience?What else would you like me to know at this point that has not been included on this questionnaire?WebsiteSubmit