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
YES
NO
Never MarriedDomestic PartnershipMarriedSeparatedDivorcedWidowed
Never Married
Domestic Partnership
Married
Separated
Divorced
Widowed

Emergency Contact


NOYES
NO
YES
NOYES
NO
YES
NOYES
NO
YES

General Health & Mental Health Information

POORUNSATISFACTORYSATISFACTORYGOODVERY GOOD
POOR
UNSATISFACTORY
SATISFACTORY
GOOD
VERY GOOD
POORUNSATISFACTORYSATISFACTORYGOODVERY GOOD
POOR
UNSATISFACTORY
SATISFACTORY
GOOD
VERY GOOD
NOYES
NO
YES
NOYES
NO
YES
NOYES
NO
YES
NOYES
NO
YES
DAILYWEEKLYMONTHLYINFREQUENTLYNEVER
DAILY
WEEKLY
MONTHLY
INFREQUENTLY
NEVER
NOYES
NO
YES

Family Mental Health History


Additional Information

NOYES
NO
YES
NOYES
NO
YES