1Booking Details

2Services

3Term & Conditions

4Term & Conditions

5Term & Conditions

6Select Date

7Payment Details

Name

First Last

Phone

Services

THERAPY INTAKE

Name

Date of birth

MM slash DD slash YYYY

Age

Phone

Sex/Gender

Male

Female

Transgender Male

Transgender Female

Genderqueer

Choose not to disclose

Is it OK to leave a message at this number?

Yes

Is it OK to send you an email?

Yes

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Employer:

School:

Current relationship status (please “X” one)

Single

Married

Partnered/Committed relationship

Separated

Divorced

Remarried

Widowed

Sexual Orientation

Straight/heterosexual

Lesbian/homosexual

Gay/homosexual

Bisexual

Something else

Don’t know

Choose not to disclose

Pronouns

He/him

She/her

They/them

Other: please specify

Name of Significant other:

Age:

Occupation:

Years Married:

Previous marriages:

yes

List

# of years married:

years of divorce:

reason for divorce:

Who currently lives in your household?

Please list age and gender of your children:

List

Gender

Age

Relationship

Are there any relationships that you are concerned about?

Abuse History:

Are you currently in an abusive relationship?

Yes

If “Yes”, check the types of abuse that apply to this relationship:

Emotional

Sexual

Financial

Spiritual

Verbal

Physical

How often does this occur?

Daily

Weekly

other

Other

Have you had past relationships that were abusive?

Yes

If “Yes”, please describe:

Were you ever sexually violated/assaulted as a child (0-18 years)?

Yes

List

If “Yes”, how old were you?

by whom?

Relationship

Have you ever been sexually assaulted or raped as an adult?

Yes

List

“Yes”, when?

by whom?

Relationship

Were charges filed?

Yes

Did you receive counseling?

Yes

Therapy History:

Are you currently receiving therapy with anyone?

Yes

Have you ever received any type of counseling services before today?

Yes

When?

From whom?

For what?

Medical History:

1. Do you have any current medical conditions (particularly seizures, diabetes, and sickle cell)?

2. Please list any mental health diagnoses received from a mental health or medical professional:

3. What treatments have you tried for these medical and mental health diagnoses?

Have you ever been hospitalized for medical reasons other than childbirth?

Yes

for what reasons?

Have you ever been hospitalized for mental health reasons?

Yes

Is there a history of drug or alcohol usage?

Yes

drug

Drug/Alcohol Type

Frequency

Is there a family history of drug or alcohol usage?

Yes

drug

Name

Describe

Are you currently taking any prescription medications? Over the counter medications?

Yes

Medication

Dosage

Prescribing Doctor

Have you ever suffered a head injury? (Car accidents, sports, violence, etc.)

10.Have you ever experienced any unusual states of consciousness like hallucinations, loss of time, long periods of confusion, out of body, etc.?

Symptom History:

Name

Phone Number

Physical Address

Email Address

4. What symptoms/problems are you hoping to improve?

5.When did these symptoms/problems first become noticeable?

6.What have been the major negative consequences of these symptoms/problems?

Please list your three primary goals for therapy.

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Consent for Telehealth
Emergency Contact
Fee Agreement
Informed Consent General
Practice Policies

Assessments

Cross Cutting Symptom Measure - Adult
Level 2 Substance Use - Adult
Severity Measure for Generalized Anxiety Disorder - Adult
Severity Measure of Depression - Adult
Severity of Posttraumatic Stress Symptoms - Adult
WHODAS 2.0 36-item

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Schedule

Interview (1 hr)

Supervision (1 hr)

Date(Required)

MM slash DD slash YYYY

Time(Required)

Hours

Minutes

AM/PM

Payment

$0.00

Name

First Last

Phone

Your Role (CHECK ONE):

Prosecutor

Defense Attorney

Plaintiff Attorney

Respondent Attorney

Client

Type of Case (Check One):

Divorce/Custody

Protective Order

Criminal

Other (Please specify)

Other

Court Date

Date

MM slash DD slash YYYY

_____________ Not yet scheduled

Approximate time needed for consultation

Hours

Minutes

AM/PM

Brief Overview of Case

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Name

First Last

Phone

Your Role (CHECK ONE):

Prosecutor

Defense Attorney

Plaintiff Attorney

Respondent Attorney

Client

Type of Case (Check One):

Divorce/Custody

Protective Order

Criminal

Other (Please specify)

Other

Court Date

Date

MM slash DD slash YYYY

_____________ Not yet scheduled

Approximate time needed for consultation

Hours

Minutes

AM/PM

Brief Overview of Case

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Supervision Contract
Fee Agreement for Supervision wRight Insight

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Registration for General Public Course

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Select Date

April 2025

Mon	Tue	Wed	Thu	Fri	Sat	Sun
	1	2	3	4	5	6
7	8	9	10	11	12	13
14	15	16	17	18	19	20
21	22	23	24	25	26	27
28	29	30

Time Duration

15 Minutes

Time Duration

45 Minutes

Payments

$0.00

Credit Card

Book An Appointment

THERAPY INTAKE

Who currently lives in your household?

Please list age and gender of your children:

Are there any relationships that you are concerned about?

Abuse History:

Therapy History:

Medical History:

Symptom History:

Please list your three primary goals for therapy.

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Assessments

Court Date

Court Date

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April 2025

Time Duration

Time Duration