Please complete the Intake Form below and bring it with you to your first appointment.

 


Anger & Stress Management Center, Inc.                         

INTAKE FORM, CONSENT TO TREATMENT AND PRIVACY PRACTICES

Name ____________________________________________________________________ Date_______________________

Address  _____________________________________________________________________________________________

City  _______________________________ State__________Zip_____________________

Home Ph. ______________________________________  Cell Ph.  ______________________________________________

Work Ph.._______________________________________  Email________________________________________________

Date of Birth_________________ Age________  Marital Status________________________________

If married, number of years married _____Spouse/Partner’s Name_______________________________________________

If separated/divorced, dates of each _______________________________________________________________________

Names of former partners________________________________________________________________________________

Names and ages of children______________________________________________________________________________

_____________________________________________________________________________________________________

Highest level of education completed_________________________________________________

Place of employment______________________________ Position_______________________________________________

Are you taking any prescription medications at this time?  YES ____  NO ____

If yes, please indicate medications and conditions for which medications are taken ___________________________________

_____________________________________________________________________________________________________

Name of prescribing physician(s) (No contact would be made without your written permission)  ____________________________________________________________________________________________________

Name of other mental health professions currently providing services to you (No contact would be made without your written permission)  __________________________________________________________________________________________

____________________________________________________________________________________________________

Emergency Contact_____________________________________________________________________________________

How did you learn about our services?  (Referral sources would not be contacted without your written permission) 

_____________________________________________________________________________________________________

Please add any comments which you think would be important for us to know

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

Please read the  Welcome Letter/Consent to Treatment dated 2013, and Notice of Privacy and sign here to indicate you have read and agree to the policies and practices.

____________________________________    ______________     ______________________________________________

Signature of Client/Custodial Parent/Guardian         Date                        Printed Name of Client