intake information

Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Date of Last Doctor's Visit

MM

DD

YYYY

Date of Last Physical

MM

DD

YYYY

Do you use non-prescription drugs?

Yes

No

Household Member #1

First Name

Last Name

Household Member #2

First Name

Last Name

Household Member #3

First Name

Last Name

Rate your level of motivation:

Low

Medium

High

Have you ever been or are you now in the military service?

Yes

No

Move or Relocation?

Yes

No

Death of a family member or friend?

Yes

No

Childbirth? Adoption?

Yes

No

Job change(s)?

Yes

No

Relationship issues?

Yes

No

Legal issues?

Yes

No

Do you exercise?

Yes

No

Abuse Type

Physical

Verbal

Emotional

Sexual