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Initial Intake Form
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Preoperative Psych Evaluation Bariatric Surgery Form
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Preoperative Psych Evaluation Bariatric Surgery Form
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Brief Intake
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Please share Information about yourself, preferences and requests. This will assist us in matching you with an appropriate provider/therapist.
Please select the service(s) that you would like us to assist you with
*
Psychotherapy
Preop Eval (Bariatric, Kidney, Cancer)
Couples
Health & Wellness - Integrative Eval
Life Coach
Weight Loss Management Program
Grief Coach
CBD & Supplements Consultation
BrainTap
Mindfulness & Relaxation Training
EMDR
Love Language Counseling
Reiki
Other (Please Specify, group, etc..)
Other
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Demographic Information of Patient (Required, please be as complete and accurate as possible)
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Date
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Name
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First
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Email
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Address
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Street Address
City
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Who are the services for?
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Date of Birth
*
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How old is the person you are inquiring about?
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Briefly describe the reason you are seeking services.
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When did it start? How often does it happen? How does it affect your life? How have you dealt with it so far?
What would you like to accomplish?
*
What is happening or is different? What stressors do you have? What do you hope will be different by seeking help?
Have you ever experienced similar or other mental health symptoms before?
*
If so, what was your experience like? When did it happen? Did you get help?
What else is important to know about you?
*
Family History, Concerns, Medications
Please check all that apply
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Anxiety
Depression
Grief/Loss
Hallucinations
OCD
Pain
Sleep
Physical or emotional abuse
Bipolar Disorder
Trauma (present or history)
Domestic Violence
Drug use or abuse
Eating disorder
Stress
Court appointment therapy
Alcohol abuse
Other
Other
*
Do you have any current or prior legal issues?
Yes, I have read and understand.
Were you ever arrested or charged with a crime or misdemeanor? Do you have any involvement with the civil courts, such as a lawsuit or family law matter? If so, please describe them. *At this time, we are unable to accommodate clients who are: • Court-ordered to attend therapy as part of legal proceedings or requirements. • Seeking documentation for disability claims or other legal/administrative purposes. We ask that clients seeking these services contact providers who specialize in these.
If you are having Suicidal Ideations please go to your nearest emergency department (Call 911 Suicide Hotline number is: 1-800-273-8255)
No Suicidal Ideations
Suicidal Ideations in the past. Non Present
Other
Other
Have you experienced any psychiatric hospitalizations? If yes, please provide the date and reason.
*
Physician's name (leave empty if none)
Psychiatrist’s name (leave empty if none)
Who Referred You?
*
Groups - Classes - Workshops - Education (Optional)
Grief Guidance Group
What's Your Love Language - Individual (International Mental Health Counselor)
Mindfulness Workshop
Other
Other
*
Please indicate your preference for a male or female therapist, or select no preference
*
No Preference
Female
Male
We provide both telehealth and in-office services. If in-office services are unavailable, we will offer telehealth instead. Please indicate your preference.
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Telehealth Preferred
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In Office Preferred
In Office Only
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About
Who we are
Our Practitioners
In The Media
Events
Resources
Careers
Press Release
Testimonials
Shop
Who we are
Our Practitioners
In The Media
Events
Resources
Careers
Press Release
Testimonials
Shop
Concerns
Anxiety
Depression
Grief & Loss
Pain
Anxiety
Depression
Grief & Loss
Pain
Relationships
Sleep Issues
Stress
Trauma
Relationships
Sleep Issues
Stress
Trauma
Our Services
Psychotherapy Services
For Adults
For Children 6-12
For Teens 13-17
For Couples
For Seniors
For Adults
For Children 6-12
For Teens 13-17
For Couples
For Seniors
Other Specialties
BrainTap
Coaching
Grief Guidance
Groups and Workshops
Reiki
BrainTap
Coaching
Grief Guidance
Groups and Workshops
Reiki
Evaluations
CBD Consultation
Brain Tap Assessment
Supplement Assessment
CBD Consultation
Brain Tap Assessment
Supplement Assessment
Forms
Brief Intake
Payment and Insurance
Registration Form
Payment Authorization
Marital Counseling
Initial Intake Form
Marital Counseling
Guidelines and Agreements
Brief Intake
Payment and Insurance
Registration Form
Payment Authorization
Marital Counseling
Initial Intake Form
Marital Counseling
Guidelines and Agreements
Preoperative Psych Evaluation Bariatric Surgery Form
Senior Residential
Referral Intake Form
CBD Waiver
PNP Medication Management
Preoperative Psych Evaluation Bariatric Surgery Form
Senior Residential
Referral Intake Form
CBD Waiver
PNP Medication Management
Insurance
925-216-3510
Get Started
