Colateral Info - Intake3-example

* Required Field

First Name * Mid

Last Name *

Email * Cell Number

Street Address City
State Zip-Code *
Country

VITALS

Date of Birth * Age * Height Weight

Race - Ethnicity
Caucasian Eurasian Black-American Hispanic European Asian Mixed

Do you have children ? Num of Boys Num of Girls

Chief Complaint - Reason for Contact

In your own words, please describe the major reason for seeking treatment

Resides with

alone
in a dorm
with parents
with child(ren)
with spouse-partner
in a blended family
in a residential facility
in military barracks

Marital Status

Single
Engaged
Married
Re-Married
Divorced
Widowed

Native language

Bi-lingual
English
Spanish
Russian
Farsi
Other

When I was born My Natural Parents were ?

intact family
blended
separated
divorced
estranged
single parent

Your Order of Birth
1st, 2nd, 3rd...
Num of Siblings
male - female

Gender

Male
Female
Trans

Practicing

practicing
non-practicing
Occassionally

Maternal Maternal Grand Mother
Maternal Grand Father
Maternal Siblings

Paternal Paternal Grand Mother
Paternal Grand Father
Paternal Siblings

Mental Health Issues Immediate Family Mother
Father
Children
Siblings
Cousins
Nephews
Nieces

Parents and Family : Drugs, Alcohol, Gambling, Addictions Mother
Father
Children
Siblings
Cousins
Nephews
Nieces