Therapeutic Consulting Intake Form

Complete the following form and content Stucker, Smith & Weatherly if you have any entering or submitting your information – (828) 515-5068. Thanks!

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Today's Date

MM slash DD slash YYYY

Person of Care Name (PoC)

Birth Date

Month

Day

Year

Driver's License #

Address

City

State

ZIP Code

Biological Sex

Gender Identity

Height

Weight

Hair Color

Eye Color

Transgender?

Yes

If yes, what stage of reassignment?

Contact Information

Cell Phone#

Alternate Phone#

Text?

Yes

Email Address

How did you hear about us?

Insurance Information

Please provide a copy of insurance card and license of primary insured if available.

Provider

Primary Insured

Policy#

Group#

Member ID#

Provider Phone#

Other

Clinical Information

Please provide any intakes, testing, or psychological assessments completed.

Primary Psychiatrist/Contact

Primary Therapist/Contact

Primary Medical/Contact

General Health?

Excellent

Good

Fair

Poor

Genomic Testing

Yes

Current Diagnoses/Behavioral Issues/Symptomology

Please attach or send any relevant clinical records

File

Max. file size: 128 MB.

Please indicate any current medications being taken:

Current Medications

Dosage

Date Started

Reason Prescribed

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Has the PoC ever attempted suicide or seriously harmed yourself?

Yes

If yes, how many times?

Latest Attempt

Has the PoC ever intentionally endangered the health, safety, or life of another person or animal?

Yes

Other Important Details

Please attach or send any relevant clinical records

Has anyone in your family attempted suicide?

Yes

Completed suicide?

Yes

Who/When?

Substance Use History

Have alcohol and/or drugs ever caused problems in any of the following areas?

Family

Employment

Academic

Legal

Emotional

Social

Financial

Behanvioral

Physical

Briefly Explain

Please list substance use history below:

Type of Drug(s) Used (THC: Hashish, Dab, etc.)

Age of 1st Use

Age of Regular Use

Avg # Days Used Per/Week

Avg Amount Used Daily

# Days Used in the Past Month

Date Last Used

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Treatment History

Please enter in your treatment history to date:

Type of Treatment Experience	How many times?	Most Recent Date	Location	Notes	Actions

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Significant major medical issues

PoC Family Information

Mother

Phone

Address

City

State

ZIP Code

Father

Phone

Address

City

State

ZIP Code

Other Parent/Guardian

Phone

Address

City

State

ZIP Code

Biological Parents

Married

Divorced

Separated

Current Relationship Status

Current Living Arrangement

Raised By

Under Guardianship

Yes

Other Involved Family Members

Children and Their Ages

Name

Age

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Siblings and Relationship Status

Name

Relationship to PoC

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Family history (check all that apply):

Mental Illness

Substance Use/Misuse/Disorder

Eating Disorder

Sexual/physical/emotional abuse

Harm to Self or Others/Suicidality

Process Disorder (Gambling, Gaming, Sex...)

Marital/Significant Partnership Status:

Single/never married

Married

Partnered

Separated

Divorced

Widowed

Living w/Someone

Married/Partnered

Single

If Married/Partnered/Single, how long?

Current Relationship Status:

Strong

Steady

Rocky

Unstable

Up & Down

Separated

Brief Description

PoC Education

Highest Level of Education Completed

Current School

Learning Differences or Identified Disabilities

College/University Apps

Educational Goal(s)

PoC Employment

Current Employer

Length of Time Employed

Job Problems

Yes

Describe

Previous Employer

Ever been fired?

Yes

If yes, how many times?

Reasons for being fired

List any special abilities, skills, or competencies

Career/Trade/Vocation of Interest

Interests/Hobbies/Activities/Strengths

Military Service

Yes

If yes, what branch?

Dates of Service

Honorable Discharge

Yes

If no, specify reason for discharge:

Legal History

Please list any criminal history below:

Arrest Date

Charge

Convicted?

Sentence

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Are you currently on Probation or Parole?

Yes

If yes, what is the end date?

Are you involved in any lawsuits, professional suspensions, or have any upcoming Court or Hearing dates?

Yes

Untitled

If so, briefly describe:

ADDITIONAL INFORMATION: (please attach additional descriptions, history, or documentation as appropriate):

Max. file size: 128 MB.

Name of individual completing form:

Relationship to PoC

Contact

Consent

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Name

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Get In Touch

Name

Phone

Message

Contact Info

Office

(828) 515-5068

Email

office@stuckersmithweatherly.com

Schedule a Call