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Deborah Lyman: Intake Form
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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
*
↓
↓
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
ZIP
*
Home Phone
*
Cell Phone
*
Other Phone
Best for Messages
Choose One...
Home Phone
Cell Phone
Other Phone
* Email Address
*
* Note: Email correspondence is not considered to be a confidential medium of communication.
May we email you?
*
YES
NO
YES
Item #1 YES
NO
Item #1 NO
Marital Status
*
Never Married
Domestic Partnership
Married
Separated
Divorced
Widowed
Never Married
Never Married
Domestic Partnership
Domestic Partnership
Married
Married
Separated
Separated
Divorced
Divorced
Widowed
Widowed
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
NO
Item #1 NO
YES
Item #1 YES
↳ If Yes, previous therapist/practitioner:
Are you currently taking any prescription medication?
*
NO
YES
NO
Item #1 NO
YES
Item #1 YES
↳ If Yes, please list:
Have you ever been prescribed psychiatric medication?
*
NO
YES
NO
Item #1 NO
YES
Item #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
POOR
Item #1 POOR
UNSATISFACTORY
Item #1 UNSATISFACTORY
SATISFACTORY
Item #1 SATISFACTORY
GOOD
Item #1 GOOD
VERY GOOD
Item #1 VERY GOOD
2. How would you rate your current sleeping habits? (Select one)
*
POOR
UNSATISFACTORY
SATISFACTORY
GOOD
VERY GOOD
POOR
Item #1 POOR
UNSATISFACTORY
Item #1 UNSATISFACTORY
SATISFACTORY
Item #1 SATISFACTORY
GOOD
Item #1 GOOD
VERY GOOD
Item #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
NO
Item #1 NO
YES
Item #1 YES
↳ If yes, for approximately how long?
6. Are you currently experiencing anxiety or panic attacks or have any phobias?
*
NO
YES
NO
Item #1 NO
YES
Item #1 YES
↳ If yes, when did you begin experiencing this?
7. Are you currently experiencing any chronic pain?
*
NO
YES
NO
Item #1 NO
YES
Item #1 YES
↳ If yes, please describe:
8. Do you drink alcohol more than once per week?
*
NO
YES
NO
Item #1 NO
YES
Item #1 YES
9. How often do you engage in recreational drug use?
*
DAILY
WEEKLY
MONTHLY
INFREQUENTLY
NEVER
DAILY
Item #1 DAILY
WEEKLY
Item #1 WEEKLY
MONTHLY
Item #1 MONTHLY
INFREQUENTLY
Item #1 INFREQUENTLY
NEVER
Item #1 NEVER
10. Are you currently in a romantic relationship?
*
NO
YES
NO
Item #1 NO
YES
Item #1 YES
↳ If yes, for how long?
↳ On a scale of 1-10, how would you rate your relationship?
Choose...
1
2
3
4
5
6
7
8
9
10
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
NO
Item #1 NO
YES
Item #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
NO
Item #1 NO
YES
Item #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?
*
Email
S U B M I T