Adult Intake



MaleFemale











Reason for seeking treatment:




YesNo
YesNo

YesNo
YesNo


YesNo

YesNo
YesNo

Substance Use History:

YesNo

Family Background:









YesNo

Marital Status:

MarriedLive with PartnerSingleSeparated/DivorcedWidowed

YesNo
YesNo
YesNo

Employment/Education Information:

EmployedRetiredDisabledStudentHomemakerUnemployed





Health/Medical Information:

Seizures YesNo
Diabetes YesNo
Thyroid Issues YesNo
Sleep Apnea YesNo












Please indicate a person who give this office permission to contact in the event of a life-threatening emergency. This two individuals should be aware that you are seeking mental health treatment.

If case of emergency, please notify:










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