Adult Intake Form | Mindful Solutions

AUTHORIZATION FOR USE OR DISCLOSURE OF

PROTECTED HEALTH INFORMATION

Purpose of Disclosure: The reason I am authorizing release is:

HOME SERVICES THERAPISTS FORMS CONTACT/LOCATION

(Adult) Intake Form

First Name

Middle Initial

Last Name

Address

Last 4 digits of social security

Cell/Other Phone

May we leave a message?

Yes

No

Date of Birth

Email

May we email you?

Yes

No

Age

Gender

Male

Female

*Please note: Email correspondence is not considered to be a confidential medium of communication.

Marital Status

Never Married

Domestic Partnership

Married

Separated

Divorced

Widowed

Sexual Orientation

Lesbian

Gay

Bisexual

Heterosexual

Don't know

Choose not to disclose

Race

Preferred Language

Veteran

Yes

No

Religion

Referred by (if any):

Please list any children/age:

Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc.)?

Yes

No

If yes, previous therapist/practitioner:

Your Signature

Date

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