Patient Intake Form

Full Name

Home Phone

Phone numbers must be in (XXX) XXX-XXXX format.

Cell Phone

Phone numbers must be in (XXX) XXX-XXXX format.

Email Address

Email Address must be in your@email.com format.

Address

Address Line 2

City

State

ZIP Code

County

Sex

Gender

Specify Gender

Your Date of Birth (DOB)

Weight (lbs)

Height (feet)

Height (inches)

Patient Registry Number (optional)

Drivers License #

Drivers License Issued State

Drivers License Photo Upload (.jpg, .png, .gif, .jpeg)

Medical Record Diagnosis (.jpg, .png, .gif, .jpeg)

Emergency Contact Name

Emergency Contact Phone #

Phone numbers must be in (XXX) XXX-XXXX format.

Primary Care Physician Name

Primary Care Physician Phone #

Phone numbers must be in (XXX) XXX-XXXX format.

Father's Name

Father's Phone #

Phone numbers must be in (XXX) XXX-XXXX format.

Mother's Name

Mother's Phone #

Phone numbers must be in (XXX) XXX-XXXX format.

Caregiver's Name

Caregiver's Phone #

Phone numbers must be in (XXX) XXX-XXXX format.

Are you scheduling an appointment for a new certification or a recertification? *

If this is a recertification, when does your current certification expire?

How did you hear about us? *

Are you being certified for PTSD? Please type yes/no. If yes, please answer the following questions related to PTSD. *

If you are being certified for PTSD, briefly describe your most traumatic event below.

1) IN THE PAST MONTH, HOW MUCH WERE YOU BOTHERED BY: Repeated, disturbing, and unwanted memories of the stressful experience?

2. IN THE PAST MONTH, HOW MUCH WERE YOU BOTHERED BY: Repeated, disturbing dreams of the stressful experience?

3. IN THE PAST MONTH, HOW MUCH WERE YOU BOTHERED BY: Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it)?

4. IN THE PAST MONTH, HOW MUCH WERE YOU BOTHERED BY: Feeling very upset when something reminded you of there stressful experience?

5. IN THE PAST MONTH HOW MUCH WERE YOU BOTHERED BY: Having strong physical reactions when something reminded you of the stressful experience (ex: heart pounding, trouble breathing, sweating)?

6. IN THE PAST MONTH, HOW MUCH WERE YOU BOTHERED BY: Avoiding memories, thoughts, or feeling related to the stressful experience?

7. IN THE PAST MONTH, HOW MUCH WERE YOU BOTHERED BY: Avoiding external reminders of the stressful experience (ex: people, places, conversations, activities, objects, or situations)?

8. IN THE PAST MONTH, HOW MUCH WERE YOU BOTHERED BY: Trouble remembering important parts of the stressful experience?

9. IN THE PAST MONTH, HOW MUCH WERE YOU BOTHERED BY: Having strong negative beliefs about yourself, other people, or the world (ex: having thoughts such as: I am bad, there is something seriously wrong with me, no one can be trusted, the world is completely dangerous)?

10. IN THE PAST MONTH, HOW MUCH WERE YOU BOTHERED BY: Blaming yourself or someone else for the stressful experience or what happened after it?

11. IN THE PAST MONTH, HOW MUCH WERE YOU BOTHERED BY: Having strong negative feelings such as fear, horror, anger, guilt or shame?

12. IN THE PAST MONTH, HOW MUCH WERE YOU BOTHERED BY: Loss of interest in activities that you used to enjoy?

13. IN THE PAST MONTH, HOW MUCH WERE YOU BOTHERED BY: Feeling distant or cut off from other people?

14. IN THE PAST MONTH, HOW MUCH WERE YOU BOTHERED BY: Trouble experiencing positive feelings (ex: being unable to feel happiness or have loving feelings for people close to you)?

15. IN THE PAST MONTH, HOW MUCH WERE YOU BOTHERED BY: Irritable behavior, angry outbursts or acting aggressively?

16. IN THE PAST MONTH, HOW MUCH WERE YOU BOTHERED BY: Taking too many risks or doing things that could cause you harm?

17. IN THE PAST MONTH, HOW MUCH WERE YOU BOTHERED BY: Being “super-alert” or watchful or on guard?

18. IN THE PAST MONTH, HOW MUCH WERE YOU BOTHERED BY: Feeling jumpy or easily startled?

19. IN THE PAST MONTH, HOW MUCH WERE YOU BOTHERED BY: Having difficulty concentrating?

20. IN THE PAST MONTH, HOW MUCH WERE YOU BOTHERED BY: Trouble falling asleep or staying asleep?

Please write your signature in the box below

Patient Intake Form

Contact Information

Patient Information

Identification Documents

Emergency Contact

Primary Care Physician

Guardian Information
If the patient is a minor, please fill out the following information.

Current Condition
If known, please tell us which condition are you currently seeking treatment for.

Additional Questions

Signature

Patient Intake Form

Contact Information

Patient Information

Identification Documents

Emergency Contact

Primary Care Physician

Guardian Information If the patient is a minor, please fill out the following information.

Current Condition If known, please tell us which condition are you currently seeking treatment for.

Additional Questions

Signature

Guardian Information
If the patient is a minor, please fill out the following information.

Current Condition
If known, please tell us which condition are you currently seeking treatment for.