Adult Intake Form

Personal Information

Name *

Email Address *

Date of Birth

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Cell Phone

Home Phone

Work Phone

I give permission to be contacted at these numbers

YesNo

Emergency Contact

Name of Emergency Contact

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Phone

I give permission to contact this person at these numbers

YesNo

Comment

Reasons for Seeking Therapy

Desired outcome or expectations of treatment (changes you would like to make, how I can help)?

Please list any people, organizations or resources you feel will help you achieve your goal

Please list any potential barriers to achieving your goal(s):

Development

Are there special, unusual and traumatic or abuse circumstances that affected your development?

YesNo

If yes, please explain

Medications

Please enter any medications, your dosage and who prescribed them

Counseling/Treatment History

Please list any prior counseling or therapy treatment

Any hospitalizations, suicidal thoughts/attempts, alcohol/drug treatment

Self help/support groups (AA, Al-Anon, Overeaters Anonymous, NA, Etc.)

Legal

Any past or current legal issues

eSignature *

I have received a copy of Elizabeth Hadley’s Professional Disclosure Statement and have had it explained to me.

Personal Information

I give permission to be contacted at these numbers

Emergency Contact

I give permission to contact this person at these numbers

Presenting reason(s) for seeking services: (check any that apply)

Reasons for Seeking Therapy

Development

Are there special, unusual and traumatic or abuse circumstances that affected your development?

Medications

Counseling/Treatment History

Legal