For office use · MRN ________ · Date ____ / ____ / ____
Welcome. Thank you for taking this first step. Please complete this form before your initial
session. Everything you share is held in confidence and helps us understand how best to support you.
There are no wrong answers, and you may skip any question you would rather discuss in person.
1
Client Information
Please print clearly
2
Emergency Contact & Insurance
3
What Brings You In
Check all that apply
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4
Background & Wellbeing Screen
Over the past two weeks
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If you are in immediate danger, please call or text 988 (Suicide & Crisis Lifeline) or dial 911.
5
Current Medications & Allergies
Medication
Dose
How often
Prescribed for
6
Consent & Acknowledgement
I acknowledge that I have received and had the opportunity to review {{ practice_name_consent }}'s
Notice of Privacy Practices, which describes how my health information may be used and disclosed in
accordance with HIPAA. I understand my information is kept confidential except where disclosure is required by
law (such as a risk of harm to myself or others, or suspected abuse).
I voluntarily consent to a psychotherapy evaluation and to treatment, and I understand I may withdraw this
consent or end treatment at any time.
I have read and understand the statements above, and the information I have provided is accurate to the best of my knowledge.
Client signature
Printed name
Date
If the client is a minor: parent / legal guardian signature ___________________________ Printed name ___________________ Date ________