Client Intake Form

Susan B. Jacobson, L.M.H.C., P.A.,  A Licensed Florida Psychotherapist

 
 
E-mail Address: *
Full Legal Name / Childs Name: *
Date: Select Date
Current Address
City:
State:
Zip:
Home Phone:
Cell / Mobile Phone:
Business / Work Phone:
Fax Number:
Client Information:Male
Female
Marital Status:Single
Married
Divorced
Widowed
Children
Date Of Birth:
SSN:
Highest Education Completed:High School
Bachelors
Masters
Religious Affiliation:
Briefly Describe Why You Are Seeking Help At This Time:
Have You Ever Seen A Mental Health Professional Before:Yes
No
If Yes, When
If Yes, With Whom
Presenting Problems:Yes
No
If Yes, Please Tell Us What You Are Being Treated For:
Your Physicians Name:
Your Physicians Telephone:
In Case Of An Emergency, Whom Should We Notify:
Emergency Telephone:
When Is The Best Time To Contact You?
Morning
Afternoon
Evening
What Is The Best Way To Contact You?
Home Phone:
Mobile Phone:
Business Phone:
Fax:
Email:
Whom May We Thank For Referring You To Our Practice:Yellow Pages
School Counselors
Brochures
Other
Message:
* Required