Forms

Person to contact in case of emergency:

Name: *

List the names and ages of the people currently living in your household:

Counseling

Intake Form:

Please provide the following information and

answer the questions below. Please note: Information

you provide in this form is protected as confidential information.

May I contact you on your work number?

Yes

Work address:

Mobile phone number *

How would you rate your spiritual health? (Please use the drop-down menu.)

Non-existent Fair Excellent

Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc.) ?

Who may I thank for referring you?

Your email address:

Do you have children?

Thank you so much for taking the time to fill out this form. After you click 'Submit,' you will be re-directed to my 'Informed Consent & Policies' form. Please take the time to read it carefully, and jot down any questions you may have. Feel free to request a hard copy if you would like one. Type any additional comments below, then click 'Submit.'

Current Employer / Profession or line of work

City *

Are you currently experiencing any chronic pain?

How often do you engage recreational drug use?

Never

1-3 times a week

3-5 times a week

5+ times a week

Do you have any pets?

How many times per week on average do you drink alcohol?

I don't drink alcohol.

1-3

3-5

5-7

Are you currently in a romantic relationship?

Date of birth *

You may send mail to my work address:

Yes

On a scale of 1-10, how would you rate your relationship currently? (Please use the drop-down menu.)

2 4 6 8 10

What is your preferred way to communicate with me? (Check all that apply)

Phone call

Text

Street address *

Are you currently receiving care from a medical doctor or psychiatrist for any reason that requires medication?

How would you rate your current emotional health?

Poor

Fair

Good

Excellent

Please list any specific health problems you are currently experiencing:

Home phone number

Has a medical doctor prescribed any medication for you?

May I leave a message on your home phone?

Yes, you can leave a message on my home phone.

No. Please do not leave me messages on my home phone.

State *

Describe the top two things you would like to accomplish in therapy:

If therapy is "successful" for you, what would life look like?

How would you rate your current physical health? (Please use the drop-down menu.)

Poor Satisfactory Very good

How would you rate your current sleeping habits? (Please use the drop-down menu.)

Poor Satisfactory Very good

Do you wish to incorporate your spiritual or religious beliefs into therapy? (For instance with prayer)

Yes, I think so.

I'm not sure.

No, definitely not.

Please list any specific sleep problems you are currently experiencing:

Please list any difficulties you experience with your appetite or eating patterns.

May I leave you a message on your mobile phone?

Yes, you can leave a message on my mobile phone.

No. Please do not leave me messages on my mobile phone.

KATY SENSMEIER, MFT

Marriage & Family Therapist

Is it okay if I text you?

Yes

Name of parent/guardian (if under 18 years):

Work phone number:

What types of exercise do you participate in?

You may send mail to my home address:

Yes

ZIP code *

How many times per week do you exercise on average?

1-3

3-5

5-7

What are some of the main things you are currently struggling with?

Are you ready to get started?

No - not yet.

Yes!

What concerns or fears do you have about counseling?