Corinne Crossley, LMHC

Intake Form

Today’s Date: ____________________________

Name: __________________________________

Address: ____________________________________________________________

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Phone number where is acceptable to contact you:___________________________

Email: _________________________________ Fax:_________________________

Preferred method of contact: _________________________________

Why are you seeking treatment at this time? (Attach other sheets as necessary.)

Primary care provider name and contact information: _________________________

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Approximate date of your last physical: _________________________________

Psychiatric provider name and contact information: __________________________

Have you ever seen a therapist before? _________________________________

Have you ever been hospitalized for a psychiatric reason? _____________________

Current medications, supplements or herbs: _______________________________

Family psychiatric history: ______________________________________________

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Preferred learning style (interactive, visual, verbal, etc.): ______________________

Hobbies/activities you enjoy doing: _______________________________________

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Referral source: _________________________________

Heath history - optional

Often the issues that we seek therapy for have a long history to them. Sometimes

they are brand-new and appear to come out of nowhere. Drawing or charting however is

most understandable to you, create a timeline of your dealings with the issue that is

bringing you in. You may include events that caused certain fluctuations or unpleasant

effects.