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Delta Center for TransformationJon Page LMFT# 100514INTAKE FORMPlease provide the following information and answer the questions below. Name: ____________________________________________ Date: ___________________________(Last)(First) (Middle Initial) Name of parent/guardian (if under 18 years): ______________________________________________ (Last) (First) (Middle Initial)Birth Date: ______ /______ /______ Age: ________ Gender: □ Male □ Female Address: ____________________________________________________________Street Address____________________________________________________________CityStateZip CodeHome Phone: ( ) _______________________ May we leave a message? □ Yes □ No Cell/Other Phone: ( ) _______________________ May we leave a message? □ Yes □ No E-mail: _____________________________________May we email you? □ Yes □ No *Please note: Email correspondence is not considered to be a confidential medium of communication. Is there someone we can call in the event of an emergency? Name:_________________________________________Relationship: ______________________Emergency Number: ( ) _______________________ May we leave a message? □ Yes □ No Referral Source:_____ CPS_____ Probation Department_____Victims of Crime_____ Health Plan of San Joaquin _____Private Pay (a) _____Insurance (b)________________________Name of Insurance Marital Status: □ Never Married □ Domestic Partnership □ Married □ Separated □ Divorced □ WidowedPlease list children/age: ____________________________________________________________________________________________________________________________________________________________________________________________________Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc.)? □ No □ Yes, previous therapist/practitioner: _________________________________________Did you ever think about committing suicide? If so, when? ________________________________________________________________________ Were medications prescribed? If so, what kind _________________________________Are you currently taking any prescription medication? □ Yes □ No Please list: _______________________________________________________________ ________________________________________________________________________ GENERAL HEALTH AND MENTAL HEALTH INFORMATION 1. How would you rate your current physical health? (please circle) Poor Unsatisfactory Satisfactory Good Very good 2. Please list any specific health problems you are currently experiencing: ________________________________________________________________________ 3. How would you rate your current sleeping habits? (please circle) Poor Unsatisfactory Satisfactory Good Very good 4. Please list any specific sleep problems you are currently experiencing: ________________________________________________________________________ 5. Are you currently experiencing overwhelming sadness, grief, or depression? □ No □ Yes If yes, for approximately how long? ___________________________________________ 6. Are you currently experiencing anxiety, panic attacks, or have any phobias? □ No □ Yes If yes, when did you begin experiencing this? ___________________________________ 7. Are you currently experiencing any chronic pain? □ No □ Yes If yes, please describe: _____________________________________________________ 8. Do you drink alcohol more than once a week? □ No □ Yes 9. Do you use, or have you used, drugs? If so, what type?__________________ □ Daily □ Weekly □ Monthly □ Infrequently □ Never 10. Are you currently in a romantic relationship? □ No □ Yes If yes, for how long? __________________ On a scale of 1-10, how would you rate your relationship? __________ 11. What stressful or traumatic events have you experienced in life? ___________________________________________________________________________________ ___________________________________________________________________________________ FAMILY HISTORY: Please list any significant family history of mental health issues (depression, anger, anxiety):_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ADDITIONAL INFORMATION: 1. Are you currently employed? □ No □ Yes ___________________________________________________________________________________2. Do you consider yourself to be spiritual or religious? □ No □ Yes If yes, describe your faith or belief: ___________________________________________________________________________________ 5. What would you like to accomplish out of your time in therapy? ___________________________________________________________________________________ ___________________________________________________________________________________ ................
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