Individual Intake Individual Intake We appreciate you taking the time to complete this online form prior to your first session. Please be sure to wait until form is sent before you close the page, otherwise the form may not be received. Thank you. PERSONAL INFORMATIONName* First Last Name of Therapist Charlotte DiPrisco, LPC Grace Donohue, MFT Jimmy Rosen, MFT Address* PO Box City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Date of birth - month, day, year* Phone* Email address* May we contact you via text?* Yes No I prefer email I prefer phone call Relationship Status* Single Engaged Married Divorced Partners How long have you been in relationship/married? Number of children List children names and ages PRESENTING PROBLEMWho referred you to JHFS?* Reason for referral.* Briefly describe presenting problem (why you have made an appointment)*How long has problem occured?* Briefly outline your goals for therapy*Briefly describe previous treatment for this issue. Who did you see before and for how long?*Please list any medications you are currently taking and for what purpose as it relates to these issuesWho is the prescribing doctor? PERSONAL HISTORYI have received individual counseling in the past.* Yes No If YES, please list provider and reason for being in individual counseling.Do you have personal history of suicide attempt/ideation?* Yes No If YES, please list dates and briefly describe historyDo you have personal history of mental health hospitalization?* Yes No If YES, please list dates and briefly describe historyPlease list personal strengths:*PERSONAL HISTORY - substance abuse/addictionsDo you have a personal history with addictions?* drugs/alcohol sex or porn food OTHER NONE Have you received previous treatment for this issue? Yes No If YES, please list dates, facility and outcomes.Are you currently using substances?* Yes No Please list all substance you are currently using and frequency of use (i.e. multiple times/day, daily, weekly, monthly)Date of last use MM slash DD slash YYYY PERSONAL HISTORY - sexual traumaDo you have personal history of sexual trauma?* Yes No If YES, please list dates/ages and briefly describe history... . to the best of your abilityHave you received previous counseling for this issue? Yes No If YES, please list dates, providers and outcomesPERSONAL HISTORY - family violenceDo you have personal history of family violence - verbal abuse or physical abuse?* Yes No If YES, please list dates/ages and briefly describe history.... to the best of your abilityHave you received previous counseling for this issue? Yes No If YES, please list dates, providers and outcomesRELATIONSHIP HISTORYI am currently in a committed relationship.* Yes No Is there relational history of domestic violence?* Yes No Who engages in violent behaviors Partner Self Both Is domestic violence ongoing? Yes No Has there been treatment for issue? Yes No If yes, please indicate if, when, where you received couples counseling for this issuePartner history of substance abuse?* Yes No Is partner currently abusing substances?* Yes No PAYMENT AGREEMENTI have read, understand & authorize the following payment policies (checking the boxes below indicates approval response ("yes"):* Credit card will be held on file and charged accordingly on dates of service Late cancellations (less than 24 hours) will yield a full fee payment for hour I will be charged full payment for "no show" sessions I authorize payments for services, late cancellations and no show fees accordingly Credit Card Information - this is a HIPPA compliant secure site*Please include: 1. credit card number 2. expiration date 3. CVV 4. Zip CodeAdditional info you feel is important for your therapist to knowAdditional questions you have regarding the counseling processCommentsThis field is for validation purposes and should be left unchanged. Δ
