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Pax & Cura - Therapy Intake Form


This confidential information is provided to you in accordance with State and Federal laws and HIPAA, including but not limited to applicable Welfare and Institutions Code, Civil Code, and Privacy Standards. Duplication of this information for further disclosure is prohibited without prior written authorization of the client/ authorized representative to whom it pertains, unless other permitted by law
Please provide the following information for our records. Leave blank any question you would rather not answer, or would prefer to discuss with your therapist. Information you provide here is held to the same standards of confidentiality as our therapy.

Full name

Gender

Date of Birth

Mobile No

Please indicate your preferred service

Please indicate your preferred service

History

Are you currently receiving professional counseling or psychotherapy elsewhere?

Are you currently taking prescribed psychiatric medication (antidepressants or others)? If yes, please list below

Are you having any problems with your sleep habits? if If yes, check where applicable:

Are you having any problems with your sleep habits? if If yes, check where applicable:

How many times per week do you exercise and approximately how long each time?

Are you having any difficulty with appetite or eating habits? If yes check where applicable

Are you having any difficulty with appetite or eating habits? If yes check where applicable

In the last year, have you experienced any significant life changes or stressors? If yes, please explain

Have you ever experienced any of the following?

Have you ever experienced any of the following?
A
B
C
D

Please select the one that best describes you

Please select the one that best describes you
A
B
C

Describe the activities that release your feel good emotions

What are the coping mechanisms you have used over time to deal with life challenges?

What is the outcome you expect from the session? (Please provide as many details as you can)