Snapdragon Counseling - Intake Form

This form is encrypted/HIPAA-compliant and your answers are kept strictly confidential. Please answer with as much detail as you feel comfortable with - of course we will discuss these things in therapy, but this info is helpful context for our first meeting!

Your Information

Your full name

Your legal name (if different)

Your gender pronouns

She/her/hers

He/him/his

They/them/theirs

Something else (write in)

Your gender identity

Your date of birth

Month

Day

Year

Your home address

Your phone number

Okay to text/leave voicemail?

Text okay

Voicemail okay

Please do not text or leave voicemail

Your email address

How do you prefer to be contacted?

Text

Phone call

Your household and support systems

Who lives with you (including pets)?

Who makes up your family (whatever that word means to you)?

Who makes up your support system?

Emergency contact name

Emergency contact phone

Is there anything you would not want shared with your emergency contact?

Your life circumstances

Are you working or in school?

What kind of income/benefits do you get?

Do you have any legal issues or background that feel important to share?

Have you ever experienced violence, abuse, or other types of traumatic incidents?

Health history

If you have a Primary Care Provider, please list their info here.

Have you been diagnosed with any physical health conditions?

Do you take any medications or supplements?

If you have health insurance, please list the type(s).

Have you been diagnosed with any mental health conditions?

Have you ever self-harmed?

Have you ever been to an Emergency Department or been hospitalized for a mental health condition?

Have you ever attempted suicide?

Do you use any substances recreationally regularly (more than once per year)?

What leads you to seek therapy? What are you interested in working on?

Is there anything else you'd like me to know?

By signing below, you are acknowledging that you have been provided copies of the Notice of Privacy Practices and Consent to Receive Therapy Services forms on my website. You have been given the opportunity to ask questions or clarify expectations, and are consenting to move forward in working with me.

Today's date

Month

Day

Year

Your signature

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Snapdragon Counseling - Intake Form

Your legal name (if different)

Your gender pronouns

She/her/hers

He/him/his

They/them/theirs

Something else (write in)

Your gender identity

Your date of birth

Month

Day

Year

Okay to text/leave voicemail?

Text okay

Voicemail okay

Please do not text or leave voicemail

How do you prefer to be contacted?

Text

Phone call

Your household and support systems

Who lives with you (including pets)?

Who makes up your family (whatever that word means to you)?

Who makes up your support system?

Emergency contact name

Emergency contact phone

Is there anything you would not want shared with your emergency contact?

Your life circumstances

Are you working or in school?

What kind of income/benefits do you get?

Do you have any legal issues or background that feel important to share?

Have you ever experienced violence, abuse, or other types of traumatic incidents?

If you have a Primary Care Provider, please list their info here.

Have you been diagnosed with any physical health conditions?

Do you take any medications or supplements?

If you have health insurance, please list the type(s).

Have you been diagnosed with any mental health conditions?

Have you ever self-harmed?

Have you ever been to an Emergency Department or been hospitalized for a mental health condition?

Have you ever attempted suicide?

Do you use any substances recreationally regularly (more than once per year)?

What leads you to seek therapy? What are you interested in working on?

Is there anything else you'd like me to know?

Today's date

Month

Day

Year

Your signature

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.