APP Mental Health Intake Form

Peace or Pain

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Home
Client Documents
Sample Documents
About Me
Blog
Services
Price
testimonial
Payment Portal
Request an Appointment

Personal Information

Full Name *

Email Address *

Phone Number *

Date of Birth *

Address *

Address

City

State/Province

Zip/Postal

Emergency Contact Name *

Emergency Phone Number *

Relationship to Emergency Contact *

Insurance Information

Full Name *

Address *

Phone Number *

Referral Information

How did you hear about us

Health History

Please indicate if you have been diagnosed or treated for any of the following conditions:

Anxiety *

Yes

Anxiety Details (When diagnosed, treatment, etc.)

Depression *

Yes

Depression Details (When diagnosed, treatment, etc.)

Bipolar Disorder *

Yes

Bipolar Disorder Details (When diagnosed, treatment, etc.)

Trauma Concerns *

Yes

Trauma Concerns Details (When diagnosed, treatment, etc.)

ADHD *

Yes

ADHD Details (When diagnosed, treatment, etc.)

Other Psychological Disorders *

Yes

Other Psychological Disorders Details (When diagnosed, treatment, etc.)

Current Medication

Please list all medications you are currently taking:

Medication Name, Dosage, Frequency, Prescribing Doctor

Mental Health Concern

Please describe your current mental health concerns and symptoms, as well as any related concerns

Work Problems, Relationship Stress, Sleep Issues, etc

Goals for Therapy

What do you hope to achieve through therapy? *

Consent for Treatment

Consent for Treatment *

I have read and understood the above information. I consent to engage in treatment with Peace or Pain Therapy. I understand that I can withdraw my consent at any time.

Signature *

Date *

If you are human, leave this field blank.

NAVIGATION

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Therapy Approaches

Cognitive Behavioral Therapy (CBT)
Action and Commitment Therapy (ACT)
Trauma Therapy
Addiction Therapy

CONTACT US

772-321-3306

hazelwood71@comcast.net

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