"Client Psychotherapy Intake Form - Rachel Goldstein, Psy. D."

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Rachel Goldstein, Psy.D.
3663 Sacramento Street
San Francisco, CA 94118-1709
www.rachelgoldsteinpsyd.com
Client Psychotherapy Intake Form
Name: ___________________________________________________________________
Birthdate: _____________
Age: ________
Gender: ________
Address: __________________________________________________________________
Phone: _______________________________
leave message? ________
Email: ___________________________________________
Name of Parent or Guardian if Under 18: ________________________________________
Emergency Contact: _________________________________________________________
Name
Phone Number
Emergency Contact Relationship: ____________________________
Referral Source (How did you hear about me):____________________________________
Marital Status:
□ Never Married
□ Separated
□ Domestic Partnership
□ Divorced
□ Married
□ Widowed
Page | 1
Rachel Goldstein, Psy.D.
3663 Sacramento Street
San Francisco, CA 94118-1709
www.rachelgoldsteinpsyd.com
Client Psychotherapy Intake Form
Name: ___________________________________________________________________
Birthdate: _____________
Age: ________
Gender: ________
Address: __________________________________________________________________
Phone: _______________________________
leave message? ________
Email: ___________________________________________
Name of Parent or Guardian if Under 18: ________________________________________
Emergency Contact: _________________________________________________________
Name
Phone Number
Emergency Contact Relationship: ____________________________
Referral Source (How did you hear about me):____________________________________
Marital Status:
□ Never Married
□ Separated
□ Domestic Partnership
□ Divorced
□ Married
□ Widowed
Page | 1
Reason for Visit: _____________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Previous Therapy:
□ No
□ Yes __________________________________________________________
Current Medication:
□ No
□ Yes __________________________________________________________
Past Medication:
□ No
□ Yes __________________________________________________________
Name of Current Psychiatrist: _______________________________________
How would you rate your current physical health?
□Poor
□Unsatisfactory
□Satisfactory
□Good
□Very good
Specific health problems you are currently experiencing:
___________________________________________________________________________
Name of Current Primary Care Provider: __________________________________________
How would you describe your sleep? _____________________________________________
How much do you exercise? ____________________________________________________
Alcohol and Drug Use:
What:_____________________
How Often: _______________________________
What:_____________________
How Often: _______________________________
How would you describe your current mood? __________________________________
_______________________________________________________________________
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Current feelings of Hopelessness:
□ No
□ Yes __________________________________________________________
Current Suicidal Ideation:
□ No
□ Yes
Plan: ____________________________________________________________
Intent: ___________________________________________________________
Access: __________________________________________________________
Previous Attempt: __________________________________________________
Current Self Harm:
□ No
□ Yes __________________________________________________________
Current Homicidal Ideation:
□ No
□ Yes __________________________________________________________
Have you ever experienced trauma or abuse?
□ No
□ Yes __________________________________________________________
Please list members of your family, including any history of mental illness for each member:
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Current Employment: _____________________________________________________
Where did you go to school? _________________________________________
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Strengths: _____________________________________________________________
Current Challenges: _____________________________________________________
What would you like to accomplish in therapy?
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
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