Contact my office 28 Market Street, Unit 4, Swansea, MAphone: 508.221.4844 email: drrachellively@gmail.com Email Psychotherapy Intake Form Psychotherapy Intake Form Address Home Phone (###) ### #### May we leave a message? Yes No Cell/Other Phone (###) ### #### Is it okay to send a text message? Yes No Email * *Please note: Email correspondence is not considered to be a confidential medium of communication. May we email you? Yes No Birthdate Gender Identity/Preferred Pronouns Relationship Status Employment Status Student Status Referred by Insurance information Primary Insurance Company ID# Subscriber’s Name Subscriber’s Address Subscriber’s Date of Birth Relationship to Patient Secondary insurance company (if applicable) ID# Group# General health and mental health information How would you rate your current physical health? (please select) Poor Unsatisfactory Satisfactory Good Very Good Please list any special health problems you are currently experiencing: How would you rate your current sleeping habits? (please select) Poor Unsatisfactory Satisfactory Good Very Good Please list any special sleep problems you are currently experiencing: How many times per week do you generally exercise? What types of exercise do you participate in? Please list any difficulties you experience with your appetite or eating patterns: Would you consider these indicative of an eating disorder? Are you currently experiencing sadness, grief, or depression? Yes No If yes, for approximately how long? Are you currently experiencing anxiety or panic attacks? Yes No If yes, when did you begin experiencing this? Are you currently experiencing any chronic pain? Yes No If yes, please describe: Have you ever experienced a traumatic event? Yes No If yes, please describe (if comfortable): Are you currently taking any prescription medication? Yes No Please list: Have you ever been prescribed medication for psychological symptoms (for example: anxiety, depression, etc.)? Yes No Please list and provide dates: Do you drink alcohol more than once a week? Yes No How often do you engage in recreational drug use? Daily Weekly Monthly Infrequently Never Are you currently in a romantic relationship? Yes No What significant life changes or stressful events have you experienced recently: Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc.)? Yes No Previous therapist/practitioner: Family mental health history In the section below, please identify if there is a family history of any of the following. If yes, please indicate the family member’s relationship to you in the space provided (father, grandmother, uncle, etc.) Alcohol/Substance Abuse Yes No If yes, please indicate the family member’s relationship to you: Anxiety Yes No If yes, please indicate the family member’s relationship to you: Depression Yes No If yes, please indicate the family member’s relationship to you: Eating Disorders Yes No If yes, please indicate the family member’s relationship to you: Obesity Yes No If yes, please indicate the family member’s relationship to you: Obsessive/Compulsive Behavior Yes No If yes, please indicate the family member’s relationship to you: Schizophrenia Yes No If yes, please indicate the family member’s relationship to you: Suicide Attempts Yes No If yes, please indicate the family member’s relationship to you: Additional information: Work Information Are you currently employed? Yes No What is your current employment situation? Do you enjoy your work? Is there anything stressful about your current work? Additional Information What do you consider to be some of your strengths? What do you consider to be some of your challenges? What would you like to accomplish in therapy? Thank you!
