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Eunice  Baek,  MFTI   Marriage  and  Family  Therapist  Intern  #IMF77276   Supervised  and  Employed  by  Patrick  L.  Healey,  LMFT  INC.     California  License  #MFC30378    

CLIENT  INTAKE     The  state  expects  that  you  will  be  informed  of  all  possible  contingencies  that  might  arise  in  the   course  of  your  short-­‐and  long-­‐term  psychotherapy.    Please  check  to  be  sure  you  have  read,   understood,  and  discussed  all  questions  with  Eunice  Baek,  MFTI.  An  informed  consent  has  the  force   of  contract,  so  we  cannot  proceed  until  we  reach  an  agreement  on  all  items.    

Background  Information    

Date_________________     Name_______________________________________________    Gender:  M/F/Other  ___________________     Home  Address________________________________________________________________________________     City  ________________________    Zip  Code_____________     Home  Phone  (_____)_______________________      OK  to  contact  Y/N     Work  Phone  (_____)______________________        OK  to  contact  Y/N     Cell  Phone  (_____)_______________________       OK  to  contact  Y/N     Email  address  ______________________________________   OK  to  contact  Y/N     Mailing  Address  (If  different)_______________________________________________________________     Date  of  Birth______________________   Social  Security  #_________________________     Physician’s  Name_____________________       Physician’s  number  (_____)__________________     Referred  By  ______________________________________________     Person  and  No.  to  call  in  emergency  _______________________________________________________    

       


If  seeking  a  sliding  scale,  you  must  complete  the  following:   Financial  Information:   Annual  household  income______________    Do  you  own  or  rent?  ____________     How  do  you  intend  to  pay  for  your  sessions?  Please  circle:  cash,  check,  charge       Areas  of  Concern   What  issues/concerns  causes  you  to  seek  mental  health  services?    Please  describe.   _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________   Do  you  have  any  specific  goals  with  regard  to  your  treatment?   _________________________________________________________________________________________________ _________________________________________________________________________________________________   Do  you  have  any  particular  concerns/fears  with  regard  to  your   treatment?____________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________   Psychological  History:   Have  you  ever  received  mental  health  treatment  before?  _________________   When  and  for  how  long?  ______________________________________________________   What  was  the  focus  of  treatment?  ____________________________________________   Name  of  treating  therapist(s),  address(es),  telephone  number(s)_______________________   _________________________________________________________________________________________________ _________________________________________________________________________________________________     Questionnaire   **Authorization  for  release  of  confidential  information  will  be  needed  so  that  any   test  administrator  may  be  contacted.   Have  you  ever  been  hospitalized  for  any  mental  or  emotional  problems?  _____________   When  and  for  how  long?  ____________________________________________________________________   Why  were  you  hospitalized?  ________________________________________________________________   Name  of  treating  therapist,  address,  telephone  number   _________________________________________________________________________________________________     **Authorization  for  release  of  confidential  information  will  be  needed  so  that  health   care  provider  may  be  contacted.   Have  you  ever  attempted  suicide?  ______________   When?  _____________________________________________  


Describe  the  circumstances  that  lead  to  that  attempt.   _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________   Are  you  currently  having  any  suicidal  thoughts?  Please  describe  _______________________   _________________________________________________________________________________________________ _________________________________________________________________________________________________   Please  describe  your  childhood.  ____________________________________________________________   _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________       Were  you  ever  subject  to  verbal,  physical,  emotional,  sexual  abuse?  Please  describe.   _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________   Have  you  ever  been  a  victim  of  a  violent  crime?  Please  describe.  _______________________   _________________________________________________________________________________________________ _________________________________________________________________________________________________     Medical  History   Have  you  ever  been  diagnosed  with  a  serious  illness?    Please  describe  ________________   _________________________________________________________________________________________________ _________________________________________________________________________________________________   Do  you  have  any  medical/physical  symptoms  you  attribute  to  metal,  emotional,  or   stress-­‐related  condition?  Please  describe  _________________________________________________   _________________________________________________________________________________________________ _________________________________________________________________________________________________   Have  you  ever  been  in  a  12-­‐step  program?  Please  describe  _____________________________   _________________________________________________________________________________________________   Do  you  smoke?  _____  How  much?  _______  For  how  long?  ____________   Do  you  drink  alcohol?  ________   On  average,  how  much  alcohol  do  you  consume  in  a  week?  _____________________________   Do  you  currently  use  illegal  drugs?    Please  describe  your  use  ___________________________   _________________________________________________________________________________________________   Have  you  ever  used  illegal  drugs?  Please  describe  _______________________________________   _________________________________________________________________________________________________     Please  include  any  additional  comments  on  the  back  page:  


Client Intake Form (Sliding Fee Scale)