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Annette Fiedler Counseling & Associates
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Intake Form & Health Assessment
Name:
Select a date
Address
Phone
Email
Birthday
Insurance:
Member #:
Phone
Name of Insured:
Relationship:
Insured Date of Birth:
Emergency Contact:
Address
Relationship:
Phone
Therapist/Counselor:
Seeking counseling:
Type of counseling you are seeking?
Consent for Treatment:
I acknowledge the above Consent for Treatment.
Statement of Confidentiality:
I acknowledge the above Statement of Confidentiality.
Health Assessment:
Last Office Visit:
Any Health Complaints:
Allergic to anything?
Do you take daily medications? Dosage & Purpose?
Do you smoke?
Yes
No
Do you drink daily?
Yes
No
How much per day?
How much per day?
Do you have any health complaints in the past 6 months?
Do you have any chronic health problems?
Do you take any over the counter medications regularly?
Have you taken any over the counter medication or vitamins this week?
Any current or previous problems with medications or alcohol?
Addiction or Abuses of alcohol or medication?
Please check any of the following symptoms you are experiencing:
Lack of sleep
Too much sleep
Lack of Appetite
Excessive Eating
Inability to Concentrate
Racing Thoughts
Lack of Motivation
Disinterest in Life
Addiction
Obsession with a specific task
Please describe what brings you to the office today:
Payment Policy:
I acknowledge the above Payment Policy. Please go to the Credit Card Authorization form by clicking this link.
Credit Card Authorization
Your Signature
Clear
Submit
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