Roene Zohler MSW, LCSW Psychotherapy, Sex Therapy, Couples Therapy

Intake Information

Name: _____________________________________________________

Address: ___________________________________________________

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Zip code: _________________ Phone: _________________________

Date of birth_______________ SSN ___________________________

MARITAL STATUS: S M D W NAME OF SPOUSE/PARTNER: __________________

Emergency Contact: ___________________________________________Phone_____________________

Relationship________________________________

What brings you to this office? ___________________________________

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How has this affected your family and/or job? ________________________

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Has there been any legal problem or any pending legal proceedings regarding this issue?

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How do you rate your physical health? Excellent Good Fair Poor

Allergies: _______________________________________________________

Illness/Injuries: Please give date & current treatment when applicable

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History of therapy,counseling and/or psychiatric treatment. Please list date, doctor, therapist, hospital, outcomes.
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Medications you are currently taking, include over the counter, herbal and/or diet supplements as well as dosage, frequency, what the drug is for , effectiveness of drug and any side effects :

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Please check the services you are interested in receiving:

__ Individual Psychotherapy

__ Marriage/Family Counseling

__ Life Coach Package

__ Workshops/Seminars

__ Individual Sex Therapy

__ Therapy/Focus Groups

__ Couples Intimacy Enrichment (Sex Therapy)

__ Other (please specify) _________________

Please rate the types of feelings you are having on a scale of 0-3 (0=not at all, 1=rarely, 2=sometimes; 3=often; 4=daily)

Anger: ____

Envious: ___

Forgetful:___

Annoyed:___

Guilty:___

Unenthusiastic:___

Sad: Happy:___

Confused:___

Depressed:___

Conflicted:___

Disappointed:___

Anxious:___

Shameful:___

Irritated:___

Fearful:___

Regretful:___

Fatigued:___

Panicky:___

Content:___

Muscle Aches:___

Overly Energetic:___

Hopeless:___

Headaches:___

Relaxed:___

Tense:___

:Digestive Pain/discomfort:___

Enthusiastic:___

Motivated:___

Jealous:___

Optimistic:___

Lonely:___

Self Actualized:___

Fear of others:___

Fear of Abandonment:___

Fear of nightmares:___

Please rate the types of behaviors or problems you may be experiencing on a scale of 0 to 3 (0=not at all, 1=rarely, 2=sometimes, 3=often, 4=daily)
Aggression:___ Depression:___ Moodiness:___ Sexual dysfunction:___ Sexual disinterest:___ Laziness: ___ Crying spells:___ Temper outbursts:___ Drug use:___ Alcohol Abuse:___ Suicide thoughts:___ Suicide attempts:___	Phobic Avoidance: ___ Can not maintain employment:___ Withdrawal:___ Sleep disturbance:___ Over spending:___ Working too much:___ No Assertiveness:___ Odd Behaviors:___ Difficulties concentrating:___ Over eating:___ Risk-taking:___ Other impulsive/compulsive behavior:___

Which of the above behaviors are currently the greatest concern for you and why?
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Is there anything else you would like me to know? __________________

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Signature: _______________________________________________

Date : __________________________________________

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