Therapy Intake Form Call Now(240) 896-5159 "*" indicates required fields Date* MM slash DD slash YYYY Table of Contents Toggle Client InformationFor Clients Under 18 Years of AgePain Assessment ToolNutrition AssessmentSuicide ScreeningIf the patient answers yes to any of the above, ask the following question: Client InformationFull Name*Preferred NameDate of Birth* MM slash DD slash YYYY AgeSocial Security#*Medicaid #*Gender*MaleFemaleRace*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone Number*Email* Emergency Contact Name/Relationship*Emergency Contact Number/Email*For Clients Under 18 Years of AgeName of Parent/Legal GuardianPhoneEmail SchoolGrade/YearReason for SeekingHave you been in Therapy before?Mental Health Diagnoses (if any)Pain Assessment Tool Pain locationPain locationHeadNeckShoulders (RT, LT, BILATERAL)Arms (RT, LT, BILATERAL)Hands (RT, LT, BILATERAL)GroinHips (RT, LT, BILATERAL)Legs (RT, LT, BILATERAL)Foot (RT, LT, BILATERALPain is worseMorningAfternoonEveningNightPatient Description of Pain- Check all that apply Sharp Dull Ache Tingles Stings Tender Throbbing Burning Other OtherUntitled Does the pain radiate? Patient Unable to describe/respond Pain Rating ScoreNutrition AssessmentFood Allergies (Confirmed or suspected) Please listHave you lost or gain 10 pounds or more in the last 3 months?YesNoHow much?Do you have a decrease in food intake and/or appetite?YesNoDo you have any Dental problems?YesNoEating habits or behaviors that may be indicators of an eating disorder,BingeingInducing vomitingPurging (use laxatives frequently)Do you avoid family dinners and social events involving food?Suicide Screening1. In the past few weeks, have you wished you were dead? Yes No 2. In the past few weeks, have you felt that you or your family would be better off if you were dead? Yes No 3. In the past week, have you been having thoughts about killing yourself? Yes No 4. Have you ever tried to kill yourself? Yes No If yes, how?When?If the patient answers yes to any of the above, ask the following question: Are you having thoughts of killing yourself right now? Yes No Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan?URLThis field is for validation purposes and should be left unchanged.
