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.
(Street & Number or P.O.)
* Note: Email correspondence is not considered to be a confidential medium of communication.
YESNO
Never MarriedDomestic PartnershipMarriedSeparatedDivorcedWidowed

Emergency Contact


NOYES
NOYES
NOYES

General Health & Mental Health Information

POORUNSATISFACTORYSATISFACTORYGOODVERY GOOD
POORUNSATISFACTORYSATISFACTORYGOODVERY GOOD
NOYES
NOYES
NOYES
NOYES
DAILYWEEKLYMONTHLYINFREQUENTLYNEVER
NOYES

Family Mental Health History


Additional Information

NOYES
NOYES