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Intake Form: Access Information
Sessions take place online via a secure version of Zoom. Do you have any concerns with your ability to join sessions in a confidential space.
Are there days or times that work best with your schedule?
Do you have extended health benefits?
Yes
No
Not Sure
If so, please provide details such as the policy, member, or identification number.
A bit more about you:
Please tell us your reason(s) for wanting therapy at this time:
Have you accessed therapy before?
Yes
No
Not Sure
If yes, please describe when and for what purpose(s).
Do you have any formal mental health diagnosis?
Yes
No
Not Sure
If yes, please provide details such as what the diagnosis is, when you received it, and by whom.
Do you have any medical conditions or issues?
Yes
No
Not Sure
If yes, please provide as much detail as you fee comfortable disclosing.
Are you taking any medication or supplements?
Yes
No
Not Sure
Any history of suicidal thoughts?
No
Yes - within the past 3 months
Yes - within the past year
Yes - more than a year ago
Not Sure
Any history of self harm?
No
Yes - within the past 3 months
Yes - within the past year
Yes - more than a year ago
Not Sure
If yes, please provide the name, dose, quantity, reason for taking, and who prescribed / recommended.
Any history of suicid attempts?
No
Yes - within the past 3 months
Yes - within the past year
Yes - more than a year ago
Not Sure
Any history of substance use?
No
Yes - within the past 3 months
Yes - within the past year
Yes - more than a year ago
Not Sure
If yes, please indicate the substance(s) of choice and period of use.
Is there anything else you would like us to know about you?
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