Individual Intake Form Name (legal): (preferred): Partner`s Name

Marriage & Family Solutions, 7818 Big Sky Dr #101 Madison WI 53719 (608) 203-6267
Individual Intake Form
Name (legal):____________________________________(preferred):____________________
Partner’s Name:___________________________________
Address:________________________________________City:___________________
State:______Zip Code:___________ Date of Birth:______________ Age:_____
Home Phone:_____________________Work/Cell phone:_________________________
Which number do you prefer we call?
Home
Cell/Work
Can we leave a message? Y N
Pharmacy:___________________________ Location:_______________________
Insurance Information:
Are we billing insurance today?
___Yes ___No
Insurance Company:_____________________ Group #:_____________________
ID#________________
Subscriber Name:________________________Subscriber Date of Birth:___________
Subscriber’s Place of Employment:___________________________
Primary Physician Name___________________________Phone:_____________
Physician Address___________________________________________________
Marital Status:
Single
Married
Divorced/Separated
Employment:
Current:___________________________
Education:
___HSED/GED
____College Graduate
____Graduate Degree
____Other
Personal History:
Briefly summarize your reason for therapy:___________________________________________
______________________________________________________________________________
Have you ever been in therapy prior to today?
Y
N
Where?______________________________ When?__________________________
Was it successful? Please explain.__________________________________________
_____________________________________________________________________
Current Medications:__________________________________________________________
Dosages:______________________________________________________________
Substance Abuse History:
Do you currently use substances (including tobacco or alcohol)?
__________________________________________
__________________________________________
Y
N
Past substance use? Y
N
__________________________________________
__________________________________________
Abuse History:
Have you ever been physically abused?
Sexual?
Y
N
Emotional? Y
N
Currently?
Y
N
Y
N
Inpatient Treatment:
Have you ever been admitted for any type of inpatient treatment, including emergency
room visits for suicidal thoughts, eating disorder or assault?
Y
N
Please explain:________________________________________________________________
____________________________________________________________________________
Emergency Contact:
Name:__________________________
Phone Number:___________________
Relation to you:___________________
Signature:__________________________
Date:______________