Intake Form

Your current Address

Your reason for consultation

Please list any psychiatric problems you have been diagnosed with:

Please list any medical or “physical” problems that you have been diagnosed with:

Please list any medications you currently take, and what you take them for:

Please tell us about any other mental health professionals you have consulted with in the past (approximate dates, type of professional seen, reason for the consultation, nature of the treatment, outcome of the treatment).

Please describe the items you have marked in the above question and/or describe "other"

Please describe the stressfull life events you have marked in the above question and/or describe "other"

What are your positive qualities and skills? What do you like about yourself? What qualities have helped you to succeed at overcoming difficulties in the past?

How motivated do you feel to work on things in therapy?

Please tell us about your plans for the future (career, personal, etc.)

What are your goals for therapy? What would you like to achieve by attending therapy?

Is there anything else that you would like to mention?

LYMINALITY

Freedom To Be. To Belong. To Become.