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» Provider Directory » Find a Therapist » New York » Lynbrook Therapists » Therapist Profile

 

Lois Plitt Warren, MPS, ATR-BC, LCAT

Intake Form - Guardian

Intake Form

Completed by parent/guardian- Please print. Use additional paper, if needed

Your answers will help to facilitate an effective beginning of the therapeutic relationship. Please attach copies of recent assessments by other mental health professionals or physicians.

Thank you for answering some difficult questions as honestly as possible. Lois

*If you would like to save paper, I recommend copying and pasting this form into a Word document and printing it out from there. Thank you.

 

Name of parent /guardian ___________________________date ____________

 

Relation to client___________________________________________________

 

Address_________________________________________________________

 

Home phone______________________ Cell Phone______________________

 

Work Phone_______________________ Email__________________________

………………………………………………………………………………………………

 

Client’s Name________________________________ Birth date ____________

 

Address__________________________________________________________

 

Home Phone ______________________ Cell Phone______________________

 

Work Phone _______________________ Email__________________________

 

Marital/Relationship Status __________________________________________

 

Education_________________________ Occupation______________________

 

Members of Family /Household:

NameAgeRelationshipLocation of residence

 

________________________________________________________________

 

________________________________________________________________

 

________________________________________________________________

 

________________________________________________________________

 

________________________________________________________________

 

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-1-

In Case of Emergency Contact:

Name___________________________________________________________

 

Relationship______________________________________________________

 

Home Phone _____________________ Cell Phone_______________________

 

Work Phone______________________Email___________________________

 

Primary Care Physician:

Name ________________________________________________________

 

Address________________________________________________________

 

Phone________________________________________________________

 

Present medical conditions, allergies, prescription and O-T-C medication______

 

________________________________________________________________

 

________________________________________________________________

 

________________________________________________________________

 

In treatment with other mental health professionals:

 

Name_________________________________Profession________________

 

Address _________________________________________________________

Phone___________________________Period of treatment_______________

 

Diagnosis________________________________________________________

 

Medication ______________________________ Dosage__________________

 

Name__________________________________Profession________________

 

Address _________________________________________________________

 

Phone___________________________Period of treatment______________

 

Diagnosis________________________________________________________

 

Medication ______________________________Dosage_________________

-2-

Referred by:

Name___________________________________________________________

Address _________________________________________________________

 

Phone___________________________________________________________

 

Email ___________________________________________________________

 

Insurance Company:

____________________________________________Phone_______________

 

Insured’s name________________________ ID#_________________________

 

Client’s ID#_______________________________________________________

 

Please use additional paper when necessary.

Primary symptoms or complaints______________________________________

 

________________________________________________________________

 

________________________________________________________________

 

________________________________________________________________

________________________________________________________________

 

________________________________________________________________

 

________________________________________________________________

 

 

Dates and conditions surrounding first appearance of each symptom__________

 

________________________________________________________________

 

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-3-

 

Other history of medical or psychiatric problems__________________________

 

________________________________________________________________

 

________________________________________________________________

 

________________________________________________________________

 

Relationship issues_________________________________________________

 

________________________________________________________________

 

________________________________________________________________________

 

Other recent stressors or pressures__________________________________

 

________________________________________________________________

 

________________________________________________________________

 

Support system ___________________________________________________

 

________________________________________________________________

 

_______________________________________________________________

 

Problems with eating, use of stressful foods and substances, and frequency of use (caffeine in coffee, tea, chocolate, soda; sugar; alcohol; drugs; tobacco)

 

________________________________________________________________

 

________________________________________________________________

 

________________________________________________________________

 

________________________________________________________________

 

Sleep habits______________________________________________________

 

________________________________________________________________

 

Physical activity____________________________________________________

 

________________________________________________________________

-4-

Creative activity____________________________________________________

 

________________________________________________________________

 

Relaxation techniques______________________________________________

 

Special interests, skills, hobbies______________________________________

 

________________________________________________________________

 

________________________________________________________________

 

Personal strengths_________________________________________________

 

________________________________________________________________

 

________________________________________________________________

 

________________________________________________________________

 

Describe any suicidal thoughts or actions_______________________________

 

________________________________________________________________

 

________________________________________________________________

 

________________________________________________________________

 

________________________________________________________________

 

Goals for art therapy_______________________________________________

 

________________________________________________________________

 

________________________________________________________________

 

________________________________________________________________

 

________________________________________________________________

 

________________________________________________________________

 

________________________________________________________________

 

________________________________________________________________

-5-

________________________________________________________________

 

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Why art therapy___________________________________________________

 

________________________________________________________________

 

________________________________________________________________

 

Other concerns or information________________________________________

 

________________________________________________________________

 

________________________________________________________________

 

________________________________________________________________

 

You may feel quite stressful after completing this form. If you would like to release some of this stress, spontaneously draw any image you desire in the space below. Do not aim for "perfect” artwork. More paper may be needed.

 

 

 

 

 


 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature_________________________________________ Date___________

-6

Lois Plitt Warren, MPS, ATR-BC, LCAT, Lynbrook

 Office Locations
Lynbrook, NY 11563
Great Neck, NY 11021

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Last Modified: 1/23/2019  


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