Intake Questionnaire | Calm Mind Behavioral

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3571 Far West Blvd #3561 Austin, TX | 78731 | 512.200.2256 | michael@calmmind.life

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Intake Questionnaire

Please fill out the following form to help us understand your overall wellness condition.

First Name

Date of Birth

I prefer to be contacted by:

Address

State

Last Name

Phone

Email Address

First Name

How were you refered to Calm Mind Behaivioral Counseling

I was refered by another therapist/counselor/psychologist/ psychiatrist

I found your profile on Psychology Today

I found your profile on Mental Health Match

I found your profile on Good Therapy

I was refered by my medical provider

I visited your facebook page or saw a facebook add

I found your website through a internet search

Someone in the legal system sugested that I work with you.

We were matched through Sondermind

We were matched through Headway

We were matched through Alma

I was refer by one of your curent or previous clients

You were refered to me by a behaioral health facility

You were refered to me by social services

Other

City

Zip Code

How are you paying for therapy

Your Insurance Carrier

Aetna

Apostrophe

BCBS

Cigna

Harvard Pilgram

Oscar Health Plan

UMR

United Health

Other

Upload a photo of the front of your insurance card.

Upload File

Upload supported file (Max 70 MB)

Upload a photo of the back of your insurance card.

Upload File

Upload supported file (Max 70 MB)

The subscriber is the person who pays for health insurance premiums or whose employment is the basis for membership in the insurance plan. If you are not the subscriber...

Subscriber full name

Subscriber date of birth

************

Sexual Preference

Gender

Relationship Status

How long have you been in this relationship

Rate quality of relationship

PoorFairGoodVery goodExcellent

Do you have children

No

Yes

Number of children

Childrens develpmental level

Infant

Toddler

Preschool

Early Childhood/School Age

Early Adolescent/Middle School

Adolescent/Highschool

Emerging adult living at home

Emerging adult living away from home

Adult Child

Health Information

Rate your physical health.

PoorFairGoodVery goodExcellent

Please select any chronic heath condition

Not Applicable

Cancer

Cardiovascular diseases, including cerebrovascular disease, heart failure, and ischemic cardiopathy

Chronic respiratory diseases, such as asthma and chronic obstructive pulmonary disease (COPD)

Other

Do you have dificulty sleeping? *

No

Yes

Please describe any sleep difficulties

Sleeping too little

Sleeping too much

Difficulty falling asleep

Difficulty staying asleep

Other

Do you exercise routinely? *

No

Yes

Please describe exercise

1-5 times/month

1-3 times/week

3-5 times/week

Daily

Do you have any problems or concerns about your appetite or food intake? *

No

Yes

Please describe Appetite

Eating significantly less

Eating significantly more

Bindging

Compensating for eating

Have you experianced significant weight change in the past 2 months? *

No

Yes

Please describe Weight

Significant weight loss

Significant weight gain

Do you regularly drink alcohol? *

No

Yes

Please describe Alcohol

1-5 times/month

1-3 times/week

3-5 times/week

Daily

Do you engage in recreational drug use? *

No

Yes

Please describe Drugs

1-5 times/month

1-3 times/week

3-5 times/week

Daily

Psychiatric Information

What prompted you to seek counseling? Select all that apply.

I am experiencing unexpected mood swings.

I feel like I have lost control.

I am undergoing a big change.

I am withdrawing from things that used to bring me joy.

I am having harmful thoughts.

I am using a substance to cope with issues in my life.

I feel helpless and hopeless.

I am feeling isolated or alone.

I am frequently worring or feeling judged.

I suspect that I might have a serious mental health condition.

My relationships feel strained.

My sleeping patterns are off.

I struggle with who I am and/or how how others percieve me.

I feel shame

I lose my temper to quickly and too often

I just feel like I need to talk to someone.

I am having difficulty reducing or stopping certain behaviors in spite of negative consequences.

Feeling sad or down more often than not.

I have been experiancing confused thinking or reduced ability to concentrate.

I am feeling detached from reality.

I am stuggling to cope with daily problems or stress

I am having trouble understanding and relating to situations and to people.

I have had a significant change in my sex drive.

I am having suicidal thoughts

Other

Have you been in counseling before?

No

Yes

Have you ever been diagnosed with an mental illness. *

No

Yes

Are you or have you ever been prescribed psychiatric medications? *

No

Yes

Thanks for submitting!

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If you are in a life threatening situation, do not use this site. Call the Suicide and Crisis Lifeline, a free, 24-hour hotline, at 988. Your call will be routed to the crisis center near you. If your issue is an emergency, call 911 or go to your nearest emergency room.

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