For potential new clients, please complete this secure and confidential online form to start the intake process. Below is an example of the information I ask for you to provide me in order to determine if we will be a good fit to work together.
- What is your cell phone number and email?
- How old are you (if you are an adult or teen seeking treatment), or how old is your child (if you are a parent)?
- What is your name (and your child/teen’s name)?
- Who referred you?
- Where do you live? (Or where does your child/teen live?)
- How interested or not interested are you (or your child/teen) in receiving treatment in general?
- Are you looking for therapy, medications, nutritional supplements, combination therapy and medication, unsure, or something else?
- If you are interested in medications would you be interested in therapy as well?
- Are you able to come in for weekly, biweekly or monthly sessions?
- Please provide a brief summary of what has been going on and what are your goals for treatment?
Past or current mental health treatment:
- Are you (or your child/teen) currently in treatment with a therapist or psychiatrist? For how long? What do you like or not like about this treatment?
- What types of treatment have you previously tried? With a therapist or psychiatrist? What was helpful or not helpful?
- What diagnoses have you (or your child/teen) received?
- If you (or your child/teen) is currently on psychiatric medication what medications and doses are prescribed? What are the effects? How long have you been taking these?
- What past medication has been tried? What doses, duration of use and effects?
- Have you (or your child/teen) had any past treatment in a psychiatric inpatient treatment facilities? How many times? Where and when was this? How long was the hospitalization?
- How much are alcohol, recreational or prescription drugs part of the picture?
- Do you have any concerns for your (or your child/teen’s) current or past substance use? Or do others share their concerns for your current or past use?
- What substances are you (or your teen/child) currently using and how much?
- Any history of suicide attempts? How many? When was the first or last time? What was tried? Did this require hospitalization (medical and/or psychiatric)?
- Any history of self injurious behaviors (such as cutting)? How long has this been going on? When did this start and when was the last time?
- Is this a current or past concern?
- If your child/teen is under 18 and if the parents are divorced, does the other parent have any legal or physical custody?
- If so, how open or not open is that parent to coming in during the assessment and/or potentially being involved in ongoing treatment?
Contact me today to start the conversation.