Mary Brasch
About
Services
Patient Portal
Contact
Adult Patient
Intake Assessment
Please enable JavaScript in your browser to complete this form.
Please enable JavaScript in your browser to complete this form.
Name
*
First
Last
Age
*
Home Address
*
Home Phone Number
*
Work Phone Number
Email
*
General Health
Please provide some information (if any) regarding the history of your physical health. Please be accurate, as medical records may need to be disclosed at some point.
Reason for Doctor's Care
If you are currently under the care of a medical professional, provide the reason as for why.
Reason for Medication
If you are currently taking any medications, please provide a reason as for why.
Physical Health Hospitalizations
If in the past you have been hospitalized for a physical aliment, please provide a description as for why.
Mental Health Hospitalizations
If in the past you have been hospitalized for a mental aliment, please provide a description as for why.
Have you had any recent major illnesses or surgeries?
*
Yes
No
Do you have any recurring or chronic conditions?
*
Yes
No
Do you smoke?
*
Yes
No
If you take any recreational drugs, what kind of drugs do you take?
Do you drink?
*
Yes
No
If you drink, how much do you drink?
Description of Previous Therapy
If you have received therapy in the past, please provide a description that may explain when, where, how long, and what for.
Occupation
How long have you held your current occupation?
Unemployment Description
If presently unemployed, please describe the situation.
Hobbies
If you have any hobbies, please describe them here.
Marital Status
*
Married
Unmarried
Divorced
Do you have any children?
*
Yes
No
Have you experienced alcoholism or domestic abuse?
*
Yes
No
Have you experienced sexual addiction or sexual abuse?
*
Yes
No
Please provide a description of anything that would be helpful for your therapist to know.
If you are currently experiencing any strong emotions, please provide a description of them below.
Do you make decisions based on these emotions? How well is that working for you at the moment?
If you feel you've experienced traumas (including in childhood), please provide a description of them below.
If you've been treated for emotional disturbances in the past, please provide a description of this below.
Are you experiencing thoughts of suicide?
*
Yes
No
If you are currently, or have in the past experienced thoughts of suicide, when was the last time you experienced these thoughts?
If you could, please provide a short explanation as for why you're seeking therapy.
What would you like to experience that is different from what you're experiencing now?
How long have you been experiencing any of the issues you're currently seeking therapy for?
What is it that you hope to achieve with therapy?
By checking the following box stating “I Agree”, you intend to affix your electronic signature agreeing to the terms and conditions specified in our privacy policy.
*
I Agree
Submit