Adult Intake Form

Please fill out the following form to the best of your ability. Do not be concerned if you do not remember everything; do the best you can. If the question does not apply, enter N/A in the response window.

* Required fields
Name *
E-mail Address *
Date of Birth *
Sex *
Marital Status *
List all household members, their age, and their relationship to you.. *
Street Address *
Town or City *
State *
Zip Code *
Home Phone Number *
Mobile Phone Number *
Do you have the ability to send and receive text messages? *
Do you have the ability to video chat? *
If you have the ability to video chat, what is your I.D.? *
Please provide your height and weight. *
Place of Employment *
Position Held *
Please provide a brief summary of your concerns. *
What are your hopes and expectations for the coaching process? *
List which of the following professionals you have seen, in an attempt to seek help for your concerns. *	Counselor General Practitioner Internist Life Coach Neurologist Private Therapist Psychologist Psychiatrist Other
Please list all mental health diagnoses you have received, by whom, and date. (month & year) *
Please provide a time line of all medications tried for all mental health diagnoses. To the best of your ability, give dose (mg.) & frequency. If you never tried medication, enter N/A. *
* Please select your preferred appointment time option. Please note, all times listed refer to EST. *
Monday between 10:00 a.m. and 12:00 p.m. Wednesday between 10:00a.m. and 12:00 p.m. Wednesday between 4:00 p.m. and 6:00 p.m. Thursday between 10:00 a.m. and 12:00 p.m. *

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