Today's Date
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MM
DD
YYYY
Name
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First Name
Last Name
How old are you?
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Date of Birth
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MM
DD
YYYY
If you are under 18 years old, please list your parent/guardian. Otherwise, type "N/A".
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Email
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Phone
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(###)
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####
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Gender
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Male
Female
Non-Binary
Transgender
Prefer Not To Say
Preferred Pronouns
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She/Her
He/Him
They/Them
Prefer Not To Say
Sexual Orientation
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Straight/Heterosexual
Gay/Homosexual
Bisexual
Pansexual
Questioning/Unsure
Prefer Not To Say
Relationship Status
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Single
Committed Relationship
Open Relationship
Widowed
Divorced
Domestic Partnership
Married
Polyamorous
How did you hear about us?
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Friend/Family
Professional Source
BetterHelp, Regain, or other associated site
Internet Search
Health Insurance Provider
(EAP) Employee Assistance Program
Other:
What are 3 of your favorite things to do on a regular basis?
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What are 3 positive qualities about yourself?
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What 3 things mean the most to me in life?
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I Am Seeking:
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Have you ever been to therapy before? If so, please include specifics about your experience.
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What is bringing you to therapy? Please describe any concerns that you'd like addressed in therapy sessions.
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What are the goals that you would like to achieve while engaging in therapy services?
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Payment for Services
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Health Insurance
Out Of Pocket
Other
Client's Relationship to Insured?
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Client (Self)
Client's Parent/Guardian
Client's Spouse
Other
I am paying for therapy services out-of-pocket and the above options do not apply to me
I authorize Tortally Therapeutics, LLC to submit health insurance claims on my behalf for services rendered to my health insurance provider.
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I authorize Tortally Therapeutics, LLC to submit health insurance claims on my behalf for services rendered to my health insurance provider.
I do not authorize Tortally Therapeutics, LLC to submit health insurance claims on my behalf for services rendered to my health insurance provider.
I am paying for therapy services out-of-pocket and the above options do not apply to me
Who is your Emergency Contact?
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The Emergency Contacts' relationship to client is:
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Parent
Legal Guardian
Spouse
Significant Other
Family Member
Friend
Emergency Contact E-mail Address is:
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Emergency Contact Phone Number is:
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(###)
###
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Are You Employed?
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Yes
No
Do You Work Part-Time or Full-Time?
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Part -Time
Full-Time
I am Unemployed
Where are you employed? What is your position/title?
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Any Current or Prior Substance Use?
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Current
Prior
None
If you have any substance use history (current use or prior use), please provide some details of the substance use. Please include the type of substance, frequency of substance use, when the substance use occurred in your life, and any concerns you have regarding the substance use. If this questions does not apply to you, type "N/A" as your response.
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Please list your current medications. (Medication name, dosage, and frequency). If not currently taking any medications, write "none".
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Have you ever been involved in any legal matters?
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Yes
No
If you have been involved in an legal matters, please explain. If this does not apply to you, please write "N/A".
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Do you have any current or prior legal challenges that are of any concern to you?
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Have you ever had any previous hospitalizations?
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Yes
No
Not Sure
If you answered "Yes" to the previous question, please provide detailed information. If the question does not pertain to you, please write "N/A"
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Have you been previously diagnosed with a mental health condition? If so, please include. If you have not been previously diagnosed with a mental health condition, please describe any symptoms that you may be experiencing.
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Any additional comments/concerns that you would like us to know?
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I attest that the information provided on this intake form is true to the best of my knowledge.
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I attest that the information provided on this intake form is true to the best of my knowledge.
Client Signature
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First Name
Last Name
