Therapy Intake Form

Name(Required)
MM slash DD slash YYYY
Have you been in therapy before?(Required)
Have you ever been hospitalized for psychiatric reasons or placed on a 5150?(Required)
Do you self-harm (like "cutting" or "burning")?(Required)
Are you currently experiencing suicidal ideations (thoughts of hurting or killing yourself)?(Required)
In your life, have you experienced trauma?(Required)
Do you drink alcohol?(Required)
Do you use recreational drugs?(Required)
Please check any of the following you have experienced in the past six months:(Required)