Fusion Care Group

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Thank you for filling out the Fusion Care Intake Form.

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Your information will be passed along to your therapist and kept confidential with the rest of your records.

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Contact Information

First Name

Last Name

Phone

Have you seen a mental health professional before?

Yes
No

Specify all medications and supplements you are presently taking and for what reason.

If taking prescription medication, who is your prescribing MD? Please include type of MD, name and phone number.

Who is your primary care physician? Please include type of MD, name and phone number.

Do you drink alcohol?

Yes
No

Do you use recreational drugs?

Yes
No

Do you have suicidal thoughts?

Yes
No

Have you ever attempted suicide?

Yes
No

Do you have thoughts or urges to harm others?

Yes
No

Have you ever been hospitalized for a psychiatric issue?

Yes
No

Is there a history of mental illness in your family?

Yes
No

We're all done!

Client Intake Form.

Contact Information

Have you seen a mental health professional before?

Specify all medications and supplements you are presently taking and for what reason.

If taking prescription medication, who is your prescribing MD? Please include type of MD, name and phone number.

Who is your primary care physician? Please include type of MD, name and phone number.

Do you drink alcohol?

Do you use recreational drugs?

Do you have suicidal thoughts?

Have you ever attempted suicide?

Do you have thoughts or urges to harm others?

Have you ever been hospitalized for a psychiatric issue?

Is there a history of mental illness in your family?

If you are in a relationship, please describe the nature of the relationship and months or years together.

Describe your current living situation. Do you live alone, with others. With family, etc...

What is your level of education? Highest grade/degree and type of degree.

What is your current occupation? What do you do? How long have you been doing it?

Please check any of the following you have experienced in the past six months.

What else would you like me to know?

What brings you to counseling at this time? Is there something specific, such as a particular event? Be as detailed as you can.

What are your goals for counseling?