"Intake Form - Adirondack Equine Assisted Psychotherapy" - New York

ADVERTISEMENT
ADVERTISEMENT

Download "Intake Form - Adirondack Equine Assisted Psychotherapy" - New York

492 times
Rate (4.4 / 5) 34 votes
Shannon Myles, LCSW c/o Haven Oaks Farm 46 Reynolds Rd. Fort Edward, NY 12828
Phone: (518) 573-0239 Fax: (518) 747-2194
info@AdirondackEAP.com
Thank you for your interest in Adirondack Equine Assisted Psychotherapy. Please complete the
following form and contact me with any questions. Thank you.
Date: ______________
Source of Referral:_________________________Phone Number:_______________________
Address:____________________________________________Fax Number:_______________
Primary Therapist:__________________________Phone Number_______________________
Address:__________________________________Fax Number:_________________________
Case Worker:_______________________________Phone Number:_____________________
Address:__________________________________Fax Number:_________________________
Emergency Contact:_________________________Phone Number_______________________
Identifying Information:
Client Name:_________________________Preferred First Name:_______________________
Address:_____________________________________________________________________
Gender:___________Marital Status:_______________Age:_____Date of Birth:_____________
Parent/Guardian:_______________________Phone Number:___________________________
Reason for Referral:___________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Pertinant History: (history of symptoms; precipitants; abuse; self-injurious behavior; level of
functioning)___________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Shannon Myles, LCSW c/o Haven Oaks Farm 46 Reynolds Rd. Fort Edward, NY 12828
Phone: (518) 573-0239 Fax: (518) 747-2194
info@AdirondackEAP.com
Thank you for your interest in Adirondack Equine Assisted Psychotherapy. Please complete the
following form and contact me with any questions. Thank you.
Date: ______________
Source of Referral:_________________________Phone Number:_______________________
Address:____________________________________________Fax Number:_______________
Primary Therapist:__________________________Phone Number_______________________
Address:__________________________________Fax Number:_________________________
Case Worker:_______________________________Phone Number:_____________________
Address:__________________________________Fax Number:_________________________
Emergency Contact:_________________________Phone Number_______________________
Identifying Information:
Client Name:_________________________Preferred First Name:_______________________
Address:_____________________________________________________________________
Gender:___________Marital Status:_______________Age:_____Date of Birth:_____________
Parent/Guardian:_______________________Phone Number:___________________________
Reason for Referral:___________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Pertinant History: (history of symptoms; precipitants; abuse; self-injurious behavior; level of
functioning)___________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Treatment History: (previous diagnoses outpatient/inpatient treatment; alcohol/substance
abuse history; treatment interventions, effects, compliance, outcome)_____________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Social History: (employment; school; teacher; IEP/504; education level; military history; legal
status)_________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Family History: (family history of mental health/substance abuse; family make up;
custody)_____________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Current Medications: (names, doses, side effects)___________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Allergies:____________________________________________________________________
____________________________________________________________________________
Diagnosis:
Axis I:_______________________________________________________________________
Axis II:______________________________________________________________________
Axis III:______________________________________________________________________
Axis IV:_____________________________________________________________________
Axis V:______________________________________________________________________
Level of Care:________________________________________________________________
Treatment Plan: (treatment goals/objectives)________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Page of 2