top of page

Intake Form

May we leave a message?
Gender

Emotional Health

Are you currently working with a Therapist?
Have there been any previous psychiatric hospitalizations
Have you been formally diagnosed with any of the following:
Have you ever had feelings or thoughts that you didn’t want to live

If YES, please answer the following. If NO, please skip to the next section.

Do you currently feel that you don’t want to live?

Sleep

Awakening during the night?
Difficulty falling asleep?
Poor or un-refreshing sleep?

PHYSICAL HEALTH

Are you happy with your weight

Self Care Practices, Please list (i.e. Yoga, Meditation, Martial Arts, Artistic Endeavors)

bottom of page