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Deborah Lyman: Intake Form

Deborah Lyman

LCSW

Intake Form

Please provide the following information and answer the questions below.
Note: Information you provide here is protected as confidential information.

Intake Form: Your Name *

First

Last

Date of Birth *

Age *

Name of Parent/Guardian (if under 18 years old)

First

Last

Mailing Address *

(Street & Number or P.O.)

City *

State *

ZIP *

Home Phone *

Cell Phone *

Other Phone

Best for Messages

* Email Address *

* Note: Email correspondence is not considered to be a confidential medium of communication.

May we email you? *

YES	NO
YESItem #1 YES	NOItem #1 NO

Marital Status *

Never Married	Domestic Partnership	Married	Separated	Divorced	Widowed
Never MarriedNever Married	Domestic PartnershipDomestic Partnership	MarriedMarried	SeparatedSeparated	DivorcedDivorced	WidowedWidowed

Please list any children/age:

Emergency Contact

Emergency Contact Name *

First

Last

Emergency Phone *

Email *

Relationship to Client *

Referred by (if any):

Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc.)? *

NO	YES
NOItem #1 NO	YESItem #1 YES

↳ If Yes, previous therapist/practitioner:

Are you currently taking any prescription medication? *

NO	YES
NOItem #1 NO	YESItem #1 YES

↳ If Yes, please list:

Have you ever been prescribed psychiatric medication? *

NO	YES
NOItem #1 NO	YESItem #1 YES

↳ If Yes, please list and provide dates:

General Health & Mental Health Information

1. How would you rate your current physical health? (Select one) *

POOR	UNSATISFACTORY	SATISFACTORY	GOOD	VERY GOOD
POORItem #1 POOR	UNSATISFACTORYItem #1 UNSATISFACTORY	SATISFACTORYItem #1 SATISFACTORY	GOODItem #1 GOOD	VERY GOODItem #1 VERY GOOD

2. How would you rate your current sleeping habits? (Select one) *

POOR	UNSATISFACTORY	SATISFACTORY	GOOD	VERY GOOD
POORItem #1 POOR	UNSATISFACTORYItem #1 UNSATISFACTORY	SATISFACTORYItem #1 SATISFACTORY	GOODItem #1 GOOD	VERY GOODItem #1 VERY GOOD

↳ Please list any specific sleep problems you are currently experiencing:

3. How many times per week do you generally exercise?

↳ What types of exercise do you participate in?

4. Please list any difficulties you experience with your appetite or eating patterns:

5. Are you currently experiencing overwhelming sadness, grief, or depression? *

NO	YES
NOItem #1 NO	YESItem #1 YES

↳ If yes, for approximately how long?

6. Are you currently experiencing anxiety or panic attacks or have any phobias? *

NO	YES
NOItem #1 NO	YESItem #1 YES

↳ If yes, when did you begin experiencing this?

7. Are you currently experiencing any chronic pain? *

NO	YES
NOItem #1 NO	YESItem #1 YES

↳ If yes, please describe:

8. Do you drink alcohol more than once per week? *

NO	YES
NOItem #1 NO	YESItem #1 YES

9. How often do you engage in recreational drug use? *

DAILY	WEEKLY	MONTHLY	INFREQUENTLY	NEVER
DAILYItem #1 DAILY	WEEKLYItem #1 WEEKLY	MONTHLYItem #1 MONTHLY	INFREQUENTLYItem #1 INFREQUENTLY	NEVERItem #1 NEVER

10. Are you currently in a romantic relationship? *

NO	YES
NOItem #1 NO	YESItem #1 YES

↳ If yes, for how long?

↳ On a scale of 1-10, how would you rate your relationship?

12. What significant life changes or stressful events have you experienced recently?

Family Mental Health History

Alcohol/substance abuse *

YES
NO

List Family Member

Anxiety *

YES
NO

List Family Member

Depression *

YES
NO

List Family Member

Domestic violence *

YES
NO

List Family Member

Eating disorders *

YES
NO

List Family Member

Obesity *

YES
NO

List Family Member

Obsessive compulsive behavior *

YES
NO

List Family Member

Schizophrenia *

YES
NO

List Family Member

Suicide attempts *

YES
NO

List Family Member

Additional Information

1. Are you currently employed? *

NO	YES
NOItem #1 NO	YESItem #1 YES

↳ If yes, what is your current employment situation?

↳ Do you enjoy your work? Is there anything stressful about your current work?

2. Do you consider yourself to be spiritual or religious? *

NO	YES
NOItem #1 NO	YESItem #1 YES

↳ If yes, please describe your faith or belief:

3. What do you consider to be some of your strengths? *

4. What do you consider to be some of your weaknesses? *

5. What would you like to accomplish out of your time in therapy? *

Name

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