Adult Intake Form This form is confidential Step 1 of 9 11% Today's Date* MM slash DD slash YYYY Your name* First Name Middle Name Last Name Date of Birth* MM slash DD slash YYYY Social Security #* Home Address* Street Address Address Line 2 City State / ProvinceAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Name of Employer* Employer Address* Street Address Address Line 2 City State / ProvinceAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneWork PhoneCell PhoneEmail Address NotesReferred byEmergency Contact* Phone*We will only contact this person if we believe it is a life or death emergency. Submission of this form represents an electronic signature indicating we may do so. SourceHow did you hear about SteppingStone Retreat?A friendReferral from a doctorInsurance companySocial mediaYellow PagesSearch engine (Google, Bing, etc)Search Phrase Marriage and Family Therapist Counselor Psychologist Non-smoker's retreat Anxiety Insurance Provider Group Number Subscriber ID EAP Authorization Number Co-Pay* Payment Method*Preferred Payment MethodCashCheckMoney OrderCashier's Check Presenting Concern*Therapy Goals*Expectations*Is the presenting concern sexual in nature?* Yes No Prefer to discuss in session Sexual Concerns The following information on this form will help guide your treatment. Please try to fill out as much as you are comfortable disclosing.Medical History*Current Medications*Do you smoke or use tobacco?* Yes No Tobacco Use - How much / often per day? Do you consume caffiene?* Yes No Caffiene Use - How much / often per day? Do you drink alcohol?* Yes No Alcohol Use - How much / often per day / week / month / year? Do you use any non-prescription drugs?* Yes No Non-prescription Drug Use - What kinds and how often? Have any of your friends or family members voiced concern about your substance use?* Yes No Have you ever been in trouble or in risky situations because of your substance use?* Yes No Current Alcohol / Substance Abuse*History of Substance Abuse*History of Substance Abuse Treatment*Medical Hospitalizations*Psychiatric Hospitalizations*Therapeutic History*Height* Weight* Age* Gender Sexual & Gender Identity* Heterosexual Transgender Lesbian Asexual Gay In Question Bisexual Other Racial / Ethnic Identity* African / African-American / Black American Indian / Alaska Native Asian / Asian-American / Asian Pacific Islander Bi-Racial / Multi-Racial Latino / Latino-American Middle Eastern / Middle Eastern-American White / European-American Not Listed / Decline to Answer Maternal Relationship*Paternal Relationship*Are your parents still married or did they divorce?* Still married Divorced Not Applicable How old were you when your parents separated or divorced and how do you think this impacted you?Other Relationships*Sisters* Brothers* Sibilng Relationships* Are you currently in a relationship?* Yes No How long have you been in your current relationship? Relationship SatisfactionExcellentPoorAre you married / life partnered?* Yes No How long have you been married / life partnered? Were you previously married / life partnered? Yes No What was the length of the previous marriages / committed partnerships? Do you have children?* Yes No How many and what are their ages? Child Relations*Household Composition*Abuse or NeglectAbuse & Neglect Discussion I prefer to discuss during our session General TraumaGeneral Trauma Discussion I prefer to discuss during our session Any specific history of sexual abuse or trauma?Sexual Abuse Discussion I prefer to discuss during our session Current level of satisfaction with your friends and social support*ExcellentPoorPlease select all sources of social support which you rely on* Friends Family Members Children Church Group Other Social Group Other Social Group Self-care and Coping Skills*Spirtuality*Spiritual Affiliation Catholic Episcopal Methodist Baptist Church of God Church of Christ Presbyterian 7th Day Adventist Pentecostal / Holiness Assembly of God Four Square Gospel Mormon Jewish Buddhist Hindu Muslim Unitarian Universalist Jehovah's Witness Quaker Pagan Druid Atheist Agnostic None How often do you attend spiritual meetings or gathering?*RegularlyOccasionallySeldomNeverPlease describe your diet*BalancedModerately BalancedUnbalanced / Poor NutritionDiet, weight, and activityDo you exercise? Yes No Type of Exercise and Frequency Vitamins*How often do you use vitamins?* Regularly Sometimes Never Education Level* High School / GED Bachelor's Degree (4 Year) Associate's Degree (2 Year) LPN RN Master's Degree Doctorate Degree PhD MD JD DDS DO OD What is your current employment?* Employment Satisfaction*ExcellentPoorCareer*Strengths*Additional InformationCheck all that apply to you currentlyNowAnxietyDepressionMood ChangesAnger or TemperPanicFearsIrritabilityConcentrationHeadachesLoss of MemoryExcessive WorryFeeling ManicTrusting OthersCommunicating with OthersDrugsAlcoholCaffeineFrequent VomitingEating ProblemsSevere Weight GainSevere Weight LossBlackoutsPeople in GeneralParentsChildrenMarriage / PartnershipFriend(s)Co-Worker(s)EmployerFinanceLegal ProblemsSexual ConcernsHistory of Child AbuseHistory of Sexual AbuseDomestic ViolenceThoughts of Hurting Someone ElseHurting SelfThoughts of SuicideSleeping Too MuchSleeping Too LittleGetting to SleepWaking Too EarlyNightmaresHead InjuryNauseaAbdominal DistressFaintingDizzinessDiarrheaShortness of BreathChest PainLump in the ThroatSweatingHeart PalpitationsMuscle TensionPain in JointsAllergiesOften Makes Careless MistakesFidget FrequentlySpeaking without ThinkingWaiting Your TurnCompleting TasksPaying AttentionEasily Distracted by NoisesHyperactivityChills or Hot FlashesCheck all that apply to you in the pastIn the PastAnxietyDepressionMood ChangesAnger or TemperPanicFearsIrritabilityConcentrationHeadachesLoss of MemoryExcessive WorryFeeling ManicTrusting OthersCommunicating with OthersDrugsAlcoholCaffeineFrequent VomitingEating ProblemsSevere Weight GainSevere Weight LossBlackoutsPeople in GeneralParentsChildrenMarriage / PartnershipFriend(s)Co-Worker(s)EmployerFinanceLegal ProblemsSexual ConcernsHistory of Child AbuseHistory of Sexual AbuseDomestic ViolenceThoughts of Hurting Someone ElseHurting SelfThoughts of SuicideSleeping Too MuchSleeping Too LittleGetting to SleepWaking Too EarlyNightmaresHead InjuryNauseaAbdominal DistressFaintingDizzinessDiarrheaShortness of BreathChest PainLump in the ThroatSweatingHeart PalpitationsMuscle TensionPain in JointsAllergiesOften Makes Careless MistakesFidget FrequentlySpeaking without ThinkingWaiting Your TurnCompleting TasksPaying AttentionEasily Distracted by NoisesHyperactivityChills or Hot FlashesMain Problem* Family History*Check all that apply Drug / Alcohol Problems Legal Trouble Domestic Violence Suicide Physical Abuse Sexual Abuse Hyperactivity Learning Disabilities Depression Anxiety Psychiatric Hospitalization "Nervous Breakdown" Arrest Record Military HistoryHave you ever served in the Armed Forces?YesNoBranch of Service US Army US Navy Air Force Marine Corps US National Guard US Army Reserves Coast Guard Dates of Services Highest Rank Achieved Where were you stationed? Discharge StatusDischarge StatusHonorableMedicalGeneralRetiredUndesirableDishonorable HIPPA Notification* The Health Insurance Portability and Accountability Act (HIPAA) has created new patient protections surrounding the use of protected health information. Commonly referred to as the “medical records privacy law”, HIPAA provides patient protections related to the electronic transmission of data (“the transaction rules”), the keeping and use of patient records (“privacy rules”), and storage and access to health care records (“the security rules”). HIPAA applies to all health care providers, including mental health care, and providers and health care agencies throughout the country are now required to provide patients a notification of their privacy rights as it relates to their health care records. You may have already received similar notices such as this one from your other health care providers. As you might expect, the HIPAA law and regulations are extremely detailed and difficult to grasp if you don’t have formal legal training. My Patient Notification of Privacy Rights is my attempt to inform you of your rights in a simple yet comprehensive fashion. Please read this document as it is important you know what patient protections HIPAA affords all of us. In mental health care, confidentiality and privacy are central to the success of the therapeutic relationship and as such, you will find I will do all I can to protect the privacy of your mental health records. If you have any questions about any of the matters discussed in this document, please do not hesitate to ask me for further clarification. By law, I am required to secure your signature indicating you have received this Patient Notification of Privacy Rights Document. Thank you for your thoughtful consideration of these matters. I understand and have been provided a copy of Dr. Boyd’s Patient Notification of Privacy Rights Document which provides a detailed description of the potential uses and disclosures of my protected health information, as well as my rights on these matters. I understand I have the right to review this document before signing this acknowledgment form.Release of PHI I have read and fully understand the Notice of Privacy Practices for Protected Health Information (PHI) offered by Dr. William R. Boyd, Jr. and Stepping Stone Retreat for Enhanced Living, LLC. In general, HIPAA privacy rules give the right to request a restriction, or release of certain restrictions regarding the use and disclosures of protected health information (PHI). An individual may also request alternate means of correspondence for confidential and protected health information. Please check all that apply below. Home Phone May leave messages with detailed information Leave message with call back number only May leave message with family member, or other person (see below) Work Phone May leave message with detailed information Leave message with call back number only Written Communication May mail to home May mail to office May fax to number below May text to number below Preferred Appointment Day*Preferred Appointment DayMondayTuesdayWednesdayThursdayAny Day is FinePreferred Appointment TimeAppointment Time - 1st ChoiceEarly. Morning 8-10Mid Morning 10-12Early Afternoon 1-3Mid Afternoon 3-6Anytime is FinePreferred Appointment TimeAppointment Time - 1st ChoiceEarly Afternoon 1-3Mid Afternoon 3-6Anytime is FineFax NumberText NumberI authorize the release of my PHI and medical information to the followingElectronic Submission* I understand that submission of this form constitutes an electronic signature authorizing the transmission of my information via email. Δ