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Intake Form

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Intake Form

1Personal information
2General health information
3Family mental health history

Name

Name of parent/guardian (if under 18 years)

Birth Date

Age

Marital Status

Please list any children/age

Address: (Street and Number)

City

State

Zip Code

Home Phone

May we leave a message?

Yes

Cell

May we leave a message?

Yes

May we email you?

Yes

Info

Please note: Email correspondence is not considered to be a confidential medium of communication.

Referred by (if any)

Have you received any type of therapy before?

Yes, previous therapist

Are you currently taking any medications?

Yes

Have you ever been prescribed psychiatric medication?

Yes

How would you rate your current physical health?

Poor

Unsatisfactory

Satisfactory

Good

Very good

Please list any specific health problems you are currently experiencing

How would you rate your current sleeping habits?

Poor

Unsatisfactory

Satisfactory

Good

Very good

Please list any specific sleep problems you are currently experiencing

How many times per week do you generally exercise?

What types of exercise to you participate in

Please list any difficulties you experience with your appetite or eating patterns

Do you drink alcohol more than once a week?

Yes

How often do you engage recreational drug use

Daily

Weekly

Monthly

Infrequently

Never

Are you currently in a romantic relationship

Yes

What significant life changes or stressful events have you experienced recently

What are some of the difficulties you are currently experiencing

What are some of your hobbies

What do you consider to be some of your strengths

What do you consider to be some of your weaknes

What would you like to accomplish out of your time together

In the section below identify if there is a family history of any of the following.

Alcohol/Substance Abuse

Yes

Anxiety

Yes

Depression

Yes

Domestic Violence

Yes

Eating Disorders

Yes

Obesity

Yes

Obsessive Compulsive Behavior

Yes

Schizophrenia

Yes

Suicide Attempts

Yes

Contact Info

If you're seeking guidance or have questions, don't hesitate to reach out. Our team is here to assist you every step of the way.

Phone

(339) 331-5350

Email

contact@leandroolszanski.com

Address

Florida, Massachusetts, Texas, New Jersey, and Georgia