Intake form for adults



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Denita Benyshek, Ph.D., Licensed Mental Health Counselor Associate

Heal & Grow Counseling, LLC

7650 SE 27th ST #503  Mercer Island, WA 98040

Telephone: 206.588.5278  Fax: 206.902.5288

denitabenyshek.phd@gmail.com  www.denitabenyshekphd.com


INTAKE FORM for ADULTS

You may use your computer to complete this Word document. Please email a copy of the completed form to Dr. Benyshek at denitabenyshek.phd@gmail.com . Thank you.


Today’s Date:

A. PERSONAL INFORMATION AND IDENTIFICATION
Name of Client:

Nickname or preferred name:

Date of Birth:

Age:


Home Address (street address, apartment number, city, state, zip code):
Mailing Address (if different than home address):
Home Phone:

May I leave a message on your home phone?


Cell Phone:

May I leave a message on your cell phone?


Work Phone:

May I leave a message on your work phone?

May I call you at work?
Skype Name:

Skype Phone Number:

May I leave a message on your Skype voicemail?

May I text you through Skype?


E-mail:

May I contact you via e-mail?




B. REFERRED BY:
Individual’s Name and Phone Number:

May I have your permission to thank this person for the referral?


Did you locate this psychotherapy practice through a website or advertisement?

If yes, what was the website or where did you see the advertisement?



C. CURRENT EMPLOYER/SCHOOL:
Occupation/Career:

Employer (name of employer, address, city, state):
Retired? Since (year):

Disabled? Since (year):


Current School/College (name of school, city, state, grade/level):
Previous Education (degrees, certificates, training):

D. YOUR MEDICAL CARE and MEDICAL HISTORY.
Primary Care Provider (Doctor/M.D.) Name:

Address:

Phone:
Do you have any medical conditions or illness at present?

If yes, please provide diagnosis:


How long have you had this condition or illness?
Current prescription medications:
Have you seen a mental health counselor, psychotherapist, psychologist, or psychiatrist previously?
Have you had thoughts of suicide in the past?
Have you thought about suicide recently?


E. EMERGENCY INFORMATION. In an emergency, whom should I contact?
Name:

Relationship:

Home Phone of Emergency Contact:

Cell Phone of Emergency Contact:

Address of Emergency Contact:


F. RELATIONSHIP STATUS.
Are you single, married, living with a domestic partner, separated, divorced, or widowed?

G. CHILDREN.
Please list all children with name, age, sex, school, grade, and indicate if full child, stepchild, or adopted child.
H. LEGAL SYSTEM.
Are you currently involved in the legal system?

If yes, please describe:


Do you have pending legal charges or are you on probation or parole?
If yes, please describe:
Have you had past involvement with the legal system?

If yes, please describe:




I. HEALTH INSURANCE.

Please note that clients pay in full for each session. Each month, I can prepare a statement that you can submit to your insurance company for reimbursement.


Please see the Disclosure and Consent to Treatment for information regarding insurance and confidentiality.
Insurance Company Name:
Insured’s I.D. Number:
Insured’s Name (first, middle initial, last):
Insured’s Address (city, state, zip):
Insured’s Telephone Number:
Insured’s Policy Number:
Insured’s Date of Birth:
Insured’s Sex (M or F):
Insured’s Employer Name and/or School Name:
Insurance Plan or Program Name:
Please bring your insurance card to your first appointment.

J. UPDATES TO PROVIDED INFORMATION.
If any of the information provided on this form changes in the future, please provide me with updated information.

Thank you for completing this form.


Please either return the form to me as an email attachment sent to denitabenyshek.phd@gmail.com or bring the printed completed form to your intake appointment.

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