New Client Intake Form Name* First Last Phone*Email* Are you contacting us regarding a DWI/DUI offense?* Yes No Are You the Client?* Yes No Client's Name* First Last Client's Phone*Client's Email* What is Your Relationship to the Client?* Best Day to Call You:* MM slash DD slash YYYY Best Time to Call You:* : Hours Minutes AM PM AM/PM What is Your Primary Concern?* Have You Sought Help for This Concern in the Past?* Yes No Please describe the help you sought:* What are your current symptoms?* Select All Anxiety Appetite issues Crying spells Depression Alcohol use Drug use Excessive energy Fatigue Guilt Hallucinations Impulsivity Irritability Libido changes Loss of interest Panic attacks Racing thoughts Risky activity Sleep changes Suspiciousness Relationship or domestic problems Trauma Illness Other Please check all that apply.Please List Other Symptom(s)* Do You Have Any Significant Medical History That We Should Know About?* Yes No Please describe:* Have You Been Evaluated by a Psychiatrist Within the Past Year?* Yes No Please describe:* Have You Been Hospitalized for a Psychiatric Illness Within the Past Year?* Yes No Please describe:* Please submit your information by clicking the button below, and we will contact you shortly to make an appointment for your first visit. Δ
