Intake Form - Individual
Please provide the following information and answer the questions below.
Please note: information you provide here is protected as confidential information.
Mental Health History:
*Please note: Email correspondence is not considered to be a confidential medium of communication.
GENERAL HEALTH AND MENTAL HEALTH INFORMATION
FAMILY MENTAL HEALTH HISTORY:
In the section below identify if there is a family history of any of the following. If yes, please indicate the family member’s relationship to you in the space provided (father, grandmother, uncle, etc.).
In case of emergency, who should be notified?
