Get New Client Intake Form - Debbie Disney, Lcsw-c

Completing the New Client Intake Form is an essential step in starting your journey with Debbie Disney, LCSW-C. This form collects important information that will help your therapist understand your needs and provide effective support.

Follow the steps to complete the intake form successfully.

1. Click the ‘Get Form’ button to access the New Client Intake Form and open it in the editor.
2. Begin with the personal details section. Enter your full name, including your last name, first name, and middle initial. If you are under 18, please also fill in the name of your parent or guardian.
3. Provide your birth date and age, followed by your gender designation.
4. Fill in the name and birth date of the primary insurance policy holder. This is important for potential coverage of services.
5. Enter your address, including street, city, state, and zip code. Be sure to double-check for accuracy.
6. Provide your home phone number. Indicate whether it is acceptable for messages to be left on this number.
7. List your cell or other phone number and note if messages or texts can be sent to this number.
8. Fill in your email address and indicate if you are comfortable with communication via email.
9. Note how you found out about the counseling center.
10. Select your current marital status by checking the appropriate box.
11. List any children you have along with their ages.
12. Indicate whether you have previously received mental health services and provide the name of your previous therapist if applicable.
13. Indicate if you have been prescribed psychiatric medication in the past and provide relevant details.
14. State if you are currently taking any prescription medication.
15. Input the names of your current physician and psychiatrist.
16. Rating your general health is essential; circle the option that best describes your current physical health.
17. Provide information on your sleeping habits and any related issues.
18. Describe your exercise routine, including frequency and type.
19. Report any current challenges regarding appetite or eating patterns.
20. Answer questions regarding feelings of sadness, anxiety, or chronic pain as applicable.
21. Discuss your relationship status and experiences with alcohol or recreational drug use.
22. Note any significant life changes or stressful events you have experienced recently.
23. Identify any family mental health history using the provided section.
24. Complete the additional information section regarding employment, education, spirituality, strengths, weaknesses, therapy goals, and any other relevant details.
25. Once you have completed all sections, save your changes, and download or print the form to bring to your first session.

Complete your New Client Intake Form online today to ensure a smooth start to your counseling journey.