Rogue Counseling
About Me
Services
New Patient Form
Schedule Appointment →
About Me
Services
New Patient Form
Schedule Appointment →
Rogue Counseling
New Patient Intake Form
Please complete the form below
Name
First Name
Last Name
Name of parent/guardian (if under 18 years):
Birth Date
Age
Gender
Marital Status
Never Married
Domestic Partnership
Married
Separated
Divorced
Widowed
Please list any children/age:
Phone
May I leave you a message/text:
Yes
No
Email Address
May I email you:
Yes
No
Referred by (if any):
Have you previously received any type of mental health services (psychotherapy, psychiatric service, etc.)?
Yes
No
If yes, previous therapist/practitoner:
Are you currently taking any prescription medications?
Yes
No
Please list:
Have you ever been prescribed psychiatric medication?
Yes
No
Please list and provide dates:
How would you rate your current physical health:
Poor
Unsatisfactory
Satisfactory
Very Good
How would you rate your current sleeping habits:
Poor
Unsatisfactory
Satisfactory
Very Good
Please list any specific health problems you are currently experiencing:
Please list any specific sleep problems you are currently experiencing:
Are you currently experiencing overwhelming sadness, grief, or depression?
Yes
No
If so, how long?
Are you currently experiencing anxiety, panic attacks or have any other phobias?
Yes
No
If so, when did you begin experiencing this:
What significant life changes or stress events have you experienced lately:
What do you consider to be some of your strengths:
What do you consider to be some of your weaknesses:
What would you like to accomplish in your time in therapy:
Thank you!