INTAKE FORM
| Dana Kovalchick, MA, LMHC Therapist for Individuals and Couples 2366 Eastlake Ave E, Suite 225, Seattle, WA 98102, 206.419.0155 |
Name: ______________________________________________________________
Street Address: ________________________________________________________
City/State/Zip: _________________________________________________________
Home Phone: ________________ Cell/Work Phone: __________________________
What phone should I use to return your calls? □ Home □ Cell □ Work
** Is it okay to leave a message at the location(s) you checked above? YES / NO **
Date of Birth: ________________ Current Age: _________ Gender: _________
Ethnicity: ________________________ Education: _________________________________
Occupation: __________________________________________________________________
Physician’s Name / Phone: ______________________________________________________
Current Medications / Reason for taking: ___________________________________________
_____________________________________________________________________________
Previous Medications (Please Describe): ___________________________________________
_____________________________________________________________________________
Have you ever seen a psychologist, psychiatrist, counselor, or therapist? □ Yes □ No
If yes, please list name and length of services: _______________________________________
_____________________________________________________________________________
What brings you to counseling? __________________________________________________
_____________________________________________________________________________
Please circle any of the following issues that are currently a struggle for you:
Anxiety Grief/Loss Physical Illness Work/Career Drugs/Alcohol
Depression Divorce/Separation Weight/Eating School Self-Harming
Mania Life Change Insomnia Family Suicidal Thoughts
Self-Esteem Sexuality Sexual Problems Finances Abuse
Fears/Phobias Relationships Obsessions Trauma/PTSD Anger
In case of an emergency, whom should I notify?
Name: __________________________ Number(s): __________________________________
Relationship to you: ____________________________________________________________
How did you hear about me? _____________________________________________________
**Is it okay for me to thank the person who gave you my name? YES / NO**
Client Signature ______________________________________ Date: __________________
