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Forms & Instructions

Your First Visit

Please fill in the information below and return it via

  • Secure online form

  • U.S. postal service

  • Or bring it with you to your first session

Download Form
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Client Intake Questionnaire

Please note: information provided on this form is protected as confidential information.

Online Form

Client Intake Questionnaire

Please note: information provided on this form is protected as confidential information.
Personal Information
May we leave a message?
May we leave a message?
May we leave a message?

* Please note: Email correspondence is not considered to be a confidential medium of communication.

Marital Status
History
Have you previously received any type of mental health services (psychotherapy services, etc.)?
Are you currently under the care of a psychiatrist?
Are you currently taking any prescription medication?
Have you ever been prescribed psychiatric medication?
General and Mental Health Information
How would you rate your current mental health?
How would you rate your current physical health?
How would you rate your current sleeping habits?
Are you currently experiencing overwhelming sadness, grief or depression?
Are you having suicidal thoughts?
Have you ever attempted suicide?
Are you currently experiencing anxiety, panics attacks or have any phobias?
Do you have history of childhood abuse (physical, sexual, or emotional) or neglect?
Are you currently experiencing any chronic pain?
How frequently do you drink alcohol?
How often do you engage in recreational drug use?
How frequently do you engage in pornography use?
Are you currently in a romantic relationship?
Family Mental Health History

In the section below, identify if there is a family history of any of the following. If yes, please indicate the family member’s relationship to you in the space provided (e.g. father, grandmother, uncle, etc.)

Alcohol/Substance Abuse
Anxiety
Depression
Sexual Porn Addiction / Multiple Infidelities
Domestic Violence
Eating Disorders
Obesity
Obsessive Compulsive Behavior
Schizophrenia
Suicide Attempts
Additional Information
Are you currently employed?
Do you enjoy your work?
Do you consider yourself to be spiritual or religious?
Consent for Treatment
and Limits of Liability

Limit of Services and Assumption of Risks

 

Therapy sessions carry both benefits and risks. Therapy sessions can significantly reduce the amount of distress someone is feeling, improve relationships, and/or resolve other specific issues. However, these improvements and any “cures” cannot be guaranteed for any condition due to the many variables that affect these therapy sessions. Experiencing uncomfortable feelings, discussing unpleasant situations and /or aspects of your life are considered risks of therapy sessions.

 

Limits of Confidentiality

 

What you discuss during your therapy session is kept confidential. No contents of the therapy sessions, whether verbal or written may be shared with another party without your written consent or the written consent of your legal guardian. The following is a list of exceptions:

 

Duty of Warn and Protect

If you disclose a plan or threat to harm yourself, the therapist must attempt to notify your family and notify legal authorities. In addition, if you disclose a plan to threat or to harm another person, the therapist is required to warn the possible victim and notify legal authorities.

 

Abuse of Children and Vulnerable Adults

If you disclose, or it is suspected, that there is abuse or harmful neglect of children or vulnerable adults (i.e. the elderly, disabled/incompetent), the therapist must report this information to the appropriate state agency and/or legal authorities.

               

History of Child Abuse in Maryland

If you disclose that you were abused as a child in the State of Maryland, and you identify your abuser, the therapist must report this to Child Protective Services, even if your abuser is deceased.

 

Prenatal Exposure to Controlled Substances

Therapists must report any admitted prenatal exposure to controlled substances that could be harmful to the mother or the child.

 

Minors/Guardianship

Parents or legal guardians of non-emancipated minor clients have the rights to access the clients’ records.

 

By signing below, I agree to the above assumption of risk and limits of confidentiality and understand their meanings and ramifications.

Thanks for submitting!