Home
Policies & Documents
Privacy & Policies
Client Intake Form
Contact
Diane Greenhill LCSW Psychotherapist
Home
Policies & Documents
Privacy & Policies
Client Intake Form
Contact
Policies & Documents
Privacy & Policies
Client Intake Form
Client Intake Form
Name
*
First Name
Last Name
Age
*
Date of Birth
*
Phone
*
(###)
###
####
May I leave a message/text?
YES
NO
Email
*
May I email you?
YES
NO
Emergency Contact
*
Phone
*
(###)
###
####
Relationship
*
How did you find me?
*
If referred, by whom?
*
Briefly, tell me about the issues/concerns that have brought you here:
*
Are you currently under the care of a primary care physician?
*
YES
NO
Physician Name
Physician Phone
Current Medical Problems
*
Current medications, including psychiatric medications and herbal preparations:
*
Are you currently or have you previously worked with a psychiatrist?
*
YES
NO
Psychiatrist’s name:
Psychiatrist’s phone:
What is/was the psychiatrist treating you for? Were you given a diagnosis?
*
Have you been on any psychiatric medications in the past?
*
Are you currently or have you previously worked with a therapist?
*
YES
NO
Therapist Name:
Therapist Phone:
What is/was the therapist treating you for? Were you given a diagnosis?
*
Have you ever been hospitalized for medical or mental health issues?
*
Have you had any previous suicide attempts?
*
Thank you!
