Psychiatric Intake Form printable pdf download

Psychiatric Intake Form

Gilbert Counseling, PLLC

3721 Benson Drive

Raleigh, NC 27609

919.659.5ZEN (936)

Intake Form

Individual Information:

Name: _____________________________________________________________________________

(Last)

(First)

(Middle Initial)

Date of Birth: _____/_____/_____

Age:_______

Gender: (circle)

Male

Female

SSN: ______--______--______

Phone: Home____________________ Work____________________ Cell_____________________

May we leave a message at: (circle)

Home

Work

Cell

Email:____________________________________ May we email you? (circle) Yes

**Email correspondence is not considered to be a confidential mode of communication.

Current Marital Status: (circle)

Single

Engaged

Partnership

Married

Separated

Divorced

Widowed

Previous Marriage(s): State length of previous marriages and if they ended by divorce, separation or

death and when:

Reason(s) for Seeking Counseling:

Please describe your reason(s) for seeking counseling:_______________________________________

How long have you been aware of these concerns?__________________________________________

Do you have some idea of how these concerns developed?____________________________________

Is anybody else aware of your concerns? Is so, who?_________________________________________

Psychiatric Intake Form