New Client Intake

skellylicsw@gmail.com
413- 842-8500

skellylicsw@gmail.com
413- 842-8500

New Client Intake

Sandra L. Kelly, LICSW
21 Paulding Drive, South Chatham, MA 02659
413-230-0508 • skellylicsw@gmail.com

Demographic Information

Name:

Intake Date:

Date of Birth:

Age:

Gender:

Preferred Pronoun:

Street Address:

City/State/Zip:

Primary Phone:

Okay to leave message? Text?

Phone Text

Cell:

Email:

Preferred Method of Contact:

Phone Text Email

Relationship Status:

Sexual Orientation:

Ethnic/Racial Identity:

Occupation:

Employer/School:

Spiritual Orientation:

Referred by:

Treatment Information

Please briefly indicate what you would like to address in therapy: [textarea treat_what class:line-multiline placeholder "" rows:3]

If you have other current healthcare or psychiatric providers, please indicate:

Primary Care Physician:

Phone:

Fax:

Address:

Last Physical Exam:

Psychiatrist:

Dates of Service:

Phone / Fax:

Medications (if any)

Medication	Dosage	Prescriber

Medical History

History of serious childhood illnesses:

Other health concerns, serious illnesses, conditions, or major operations requiring hospitalization during your life time, please explain:

Have you experienced any head injuries?

Yes No

If yes, did you lose consciousness?

Y N

Have you experienced convulsions or seizures?

Yes No

Explain any allergies you have:

Substance Abuse History

Do you drink alcohol?

Yes No If yes, how frequently? and how many drinks

Have you ever blacked out from drinking?

Yes No If yes, number of times:

Have you ever needed medical attention due to use of substances?

Yes No If Yes please explain:

Do you use other illegal substances?

Yes No If yes, list substances & frequency:

Eating disorders Addendum

Ritualistic Behavior (Around food and Separate from food): please explain:

Behavior	Current Amount/Frequency	Past History — Max/Min (Date)
Binging
Vomiting
Restricting Calories
Laxatives
Diet Pills
Diuretics
Exercise
Caffeine use

Medical issues related to Eating Disorder: please check all that apply

Night Eating / Binge Eating Questions

1. Do you wake at least once during the night to eat?

Yes No

2. If you wake up in the night, do you find that it is necessary to eat something in order to fall back asleep again?

Yes No

3. Do you have little or no appetite in the morning and feel very hungry in the evening, often overeating between dinner and when you go to bed?

Yes No

Trauma, Miscellaneous, etc

Are you experiencing suicidal ideation?

Yes No

If yes, do you have intent or plans of harming yourself?

Are you experiencing homicidal ideation?

Yes No

If yes, do you have intent or plans of harming someone?

Have you experienced traumatic events in your life (physical, sexual, emotional abuse, witnessing traumatic events, death of friend or family member, car accidents, etc.)? If so, please provide a brief explanation:

Please indicate any other information that would be important or helpful to know about you:

Emergency Contact Information

Name:

Relationship:

Street Address:

City/State/Zip:

Primary Phone:

Ok to leave message?

Yes No

Secondary Phone:

Ok to leave message?

Yes No