Intake Form | Annette Fiedler

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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:

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? * Required

Yes

No

Do you drink daily? * Required

Yes

No

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

Annette Fiedler Counseling & Associates

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