Consultative Diagnostic Intake - Asher Fox, CCHt

Name: *
Email: *
Cell Phone: *
Street Address:
City:
State:
ZIP Code:
Time Zone:

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New Client Intake 

Please note: Information provided on this form is protected as confidential information.

Personal Information

Name:
{"type":"text","name":"clientFullName","width":80,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in your Full Name.","placeholder":""}


Parent/Legal Guardian (if under 18):{"type":"text","name":"clientGuardianName","width":80,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":""}

Address:
{"type":"text","name":"clientAddress","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":""}

City:
{"type":"text","name":"__generic","width":80,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":""}


State:                                      ZIP
{"type":"text","name":"__generic2","width":20,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":""}

               {"type":"text","name":"__generic3","width":20,"value":"","size":"Normal","validation":"TN","validationMessage":"Please enter a number.","placeholder":""}

Mobile:
{"type":"text","name":"clientMobilePhone","width":100,"value":"","size":"Normal","validation":"TI","validationMessage":"Please enter your Mobile Phone Number.","placeholder":""}

Home:
{"type":"text","name":"clientHomePhone","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":""}

Email:
{"type":"text","name":"clientEmail","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in your Email address.","placeholder":""}



Date of Birth: {"type":"text","name":"clientDOB","width":25,"value":"","size":"Normal","validation":"DV","validationMessage":"Please fill in this item.","placeholder":"MM/DD/YYYY"}

    Age: {"type":"text","name":"clientAge","width":10,"value":"","size":"Normal","validation":"TP","validationMessage":"Please fill in this item.","placeholder":""}

    Gender: SelectMaleFemaleOtherI prefer not to sayWill discuss in session{"type":"select","name":"clientGender","width":20,"value":"","size":"Normal","validation":"N1","validationMessage":"Please make a selection for this item.","options":"Select\nMale\nFemale\nOther\nI prefer not to say\nWill discuss in session"}


Marital Status:
{"type":"radio","name":"clientMaritalStatus","width":50,"value":"","size":"Normal","validation":"C1","validationMessage":"Please make a selection for this item.","options":"Never Married\nDomestic Partnership\nMarried\nSeparated\nDivorced\nWidowed"}



Referred By (if anyone): {"type":"text","name":"clientReferredBy","width":50,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":""}


Full Life Snapshot

Please take a moment to evaluate your experience over the past week in the following areas using the 1 to 5 scale shown below.

Remember to apply the following rule of thumb:
5 is "I'm doing awesome here, couldn't ask for more!
4 is "I'm doing great, no complaints!
3 is "I'm doing okay, though could be better
2 is "I'm kinda rough or lacking this area
1 is "I'm not doing well, this is a problem
0 is "gah, total failure!"

Area of Life/
Life Skill
Score
Self-Esteem {"type":"radio","name":"family","width":15,"value":"","size":"Normal","validation":"C1","validationMessage":"Please rate on family","options":"0\n1\n2\n3\n4\n5"}

Strong Boundaries {"type":"radio","name":"fitness","width":15,"value":"","size":"Normal","validation":"C1","validationMessage":"Please rate on fitness","options":"0\n1\n2\n3\n4\n5"}

Positive Self-Talk {"type":"radio","name":"fitness2","width":15,"value":"","size":"Normal","validation":"C1","validationMessage":"Please rate on fitness","options":"0\n1\n2\n3\n4\n5"}

Self-Care {"type":"radio","name":"fitness3","width":15,"value":"","size":"Normal","validation":"C1","validationMessage":"Please rate on fitness","options":"0\n1\n2\n3\n4\n5"}

Family Life
 {"type":"radio","name":"fitness4","width":15,"value":"","size":"Normal","validation":"C1","validationMessage":"Please rate on fitness","options":"0\n1\n2\n3\n4\n5"}

Friendships {"type":"radio","name":"fitness5","width":15,"value":"","size":"Normal","validation":"C1","validationMessage":"Please rate on fitness","options":"0\n1\n2\n3\n4\n5"}

Intimacy/Sex {"type":"radio","name":"fitness6","width":15,"value":"","size":"Normal","validation":"C1","validationMessage":"Please rate on fitness","options":"0\n1\n2\n3\n4\n5"}

Professional/Work {"type":"radio","name":"work","width":15,"value":"","size":"Normal","validation":"C1","validationMessage":"Please rate on work","options":"0\n1\n2\n3\n4\n5"}

Prosperity {"type":"radio","name":"prosperity","width":15,"value":"","size":"Normal","validation":"C1","validationMessage":"Please rate on purpose","options":"0\n1\n2\n3\n4\n5"}

Goal Achievement {"type":"radio","name":"purpose","width":15,"value":"","size":"Normal","validation":"C1","validationMessage":"Please rate on purpose","options":"0\n1\n2\n3\n4\n5"}

Health/Fitness
 {"type":"radio","name":"purpose2","width":15,"value":"","size":"Normal","validation":"C1","validationMessage":"Please rate on purpose","options":"0\n1\n2\n3\n4\n5"}

Sense of Purpose
 {"type":"radio","name":"purpose3","width":15,"value":"","size":"Normal","validation":"C1","validationMessage":"Please rate on purpose","options":"0\n1\n2\n3\n4\n5"}

Totals/Average:  
 {"type":"computed","name":"totalScore","width":20,"value":"","size":"Normal","validation":null,"validationMessage":null,"formula":"family+fitness+work+prosperity+purpose","hidden":false}

 or  {"type":"computed","name":"percentageAwesome","width":20,"value":"","size":"Jumbo","validation":null,"validationMessage":null,"formula":"(totalScore/25)*100","hidden":false}

 % of full life satisfaction

Comments:

History

1. Have you ever worked with a psychotherapist, hypnotherapist, mental health coach or other practitioner?
{"type":"radio","name":"clientPreviousService","width":20,"value":"","size":"Normal","validation":"C1","validationMessage":"Please choose one of the above options.","options":"No\nYes"}


2. How many practitioners have you worked with previously: {"type":"text","name":"clientPreviousService_comment","width":10,"value":"","size":"Normal","validation":"TN","validationMessage":"Please fill in this item.","placeholder":""}


What type of practitioners were they and what was your experience?
{"type":"textarea","name":"__generic4","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":"What did you like or dislike? What results did you see?"}



Which of the following types of practitioners/modalities do you believe you've tried? 
{"type":"radio","name":"clientPrescriptionMedication","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please make a selection for this item.","options":"Cognitive Behavioral\nPsychodynamic\nClinical Hypnotherapy\nFamily Systems Therapy\nEMDR/Eye Movement Therapy\nEFT (Tapping)\nCoaching\nOther\nNone"}


Were any of these more effective than others and if so, why?{"type":"textarea","name":"clientPrescriptionMedication_comment","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":""}


Self-Care Profile


1. How would you rate your current physical Health?{"type":"radio","name":"clientCurrentPhysicalHealth","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please make a selection for this item.","options":"Poor\nUnsatisfactory\nSatisfactory\nGood\nVery Good"}

Please list any specific health problems you are currently experiencing:{"type":"textarea","name":"clientCurrentPhysicalHealth_comment","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":""}


2. How would you rate your current sleeping habits?{"type":"radio","name":"clientCurrentSleepingHabits","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please make a selection for this item.","options":"Poor\nUnsatisfactory\nSatisfactory\nGood\nVery Good"}

Please list any specific sleep problems you are currently experiencing:{"type":"textarea","name":"clientCurrentSleepingHabits_comment","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":""}


3. How many times per week do you generally exercise or get significant physical activity?
Select1234567{"type":"select","name":"__generic","width":20,"value":"","size":"Normal","validation":"N1","validationMessage":"Please make a selection for this item.","options":"Select\n1\n2\n3\n4\n5\n6\n7"}


What types of exercise do you participate in?{"type":"textarea","name":"clientExercisePerWeek_comment","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":""}


4. Please list any difficulties you experience with your appetite, or any eating problems:{"type":"textarea","name":"clientCurrentAppetite","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":""}


5. Are you currently experiencing overwhelming sadness and/or grief?
{"type":"radio","name":"clientSadness","width":20,"value":"","size":"Normal","validation":"C1","validationMessage":"Please make a selection for this item.","options":"No\nYes"}

If yes, for approximately how long?{"type":"text","name":"clientSadness_comment","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":""}


6. Are you currently experiencing anxious feelings, panic attacks, or have any phobias?
{"type":"radio","name":"clientAxietyPanicPhobia","width":20,"value":"","size":"Normal","validation":"C1","validationMessage":"Please make a selection for this item.","options":"No\nYes"}

If yes, when did you begin experiencing this?{"type":"textarea","name":"clientAxietyPanicPhobia_comment","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":""}


7. Are you currently experiencing any chronic pain?
{"type":"radio","name":"clientChronicPain","width":20,"value":"","size":"Normal","validation":"C1","validationMessage":"Please make a selection for this item.","options":"No\nYes"}

If yes, please describe:{"type":"textarea","name":"clientChronicPain_comment","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":""}


8. Do you drink alcohol more than once a week?
{"type":"radio","name":"clientAlcoholConsumption","width":20,"value":"","size":"Normal","validation":"C1","validationMessage":"Please make a selection for this item.","options":"No\nYes"}


9. How often do you engage in recreational drug use?{"type":"radio","name":"clientDrugUse","width":100,"value":"","size":"Normal","validation":"C1","validationMessage":"Please make a selection for this item.","options":"Daily\nWeekly\nMonthly\nInfrequently\nNever"}


10. Are you currently in a romantic relationship?
Relationship status?No, I'm singleYes, I'm marriedYes, I'm in a committed relationshipYes, I'm in an open relationshipI prefer not to say{"type":"select","name":"clientRomanticRelationship","width":40,"value":"","size":"Normal","validation":"N1","validationMessage":"Please make a selection for this item.","options":"Relationship status?\nNo, I'm single\nYes, I'm married\nYes, I'm in a committed relationship\nYes, I'm in an open relationship\nI prefer not to say"}

For approximately how long have you been in this relationship or been single?{"type":"text","name":"clientRomanticRelationship_comment","width":50,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","placeholder":""}


11. On a scale of 1-10 (with 1 being poor and 10 being exceptional), how would you rate your relationship?
Select12345678910{"type":"select","name":"__generic6","width":35,"value":"","size":"Normal","validation":"","validationMessage":"Please make a selection for this item.","options":"Select\n1\n2\n3\n4\n5\n6\n7\n8\n9\n10"}



12. What, if any, significant life changes or stressful events have you experienced recently?{"type":"textarea","name":"clientStressfulEvents","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":""}


Family Mental Health History

In the section below, indicate whether you or a family member have a history of any of the following conditions. If the answer is "yes" for yourself, please provide details. If it applies to a family member, specify their relationship to you and give details in the space provided (e.g., father, grandmother, uncle, etc.).

Alcohol / Substance Abuse
{"type":"radio","name":"clientFamilyAlcoholSubstance","width":20,"value":"","size":"Normal","validation":"C1","validationMessage":"Please make a selection for this item.","options":"Yes\nNo"}


{"type":"text","name":"clientFamilyAlcoholSubstance_comment","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":"List family members with history here (mother, father, etc.)..."}


Anxiety
{"type":"radio","name":"clientFamilyAnxiety","width":20,"value":"","size":"Normal","validation":"C1","validationMessage":"Please make a selection for this item.","options":"Yes\nNo"}


{"type":"text","name":"clientFamilyAnxiety_comment","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":"List family members with history here (mother, father, etc.)..."}


Depression
{"type":"radio","name":"clientFamilyDepression","width":20,"value":"","size":"Normal","validation":"C1","validationMessage":"Please make a selection for this item.","options":"Yes\nNo"}


{"type":"text","name":"clientFamilyDepression_comment","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":"List family members with history here (mother, father, etc.)..."}


Domestic Violence
{"type":"radio","name":"clientFamilyDomesticViolence","width":20,"value":"","size":"Normal","validation":"C1","validationMessage":"Please make a selection for this item.","options":"Yes\nNo"}


{"type":"text","name":"clientFamilyDomesticViolence_comment","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":"List family members with history here (mother, father, etc.)..."}


Eating Disorders
{"type":"radio","name":"clientFamilyEatingDisorders","width":20,"value":"","size":"Normal","validation":"C1","validationMessage":"Please make a selection for this item.","options":"Yes\nNo"}


{"type":"text","name":"clientFamilyEatingDisorders_comment","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":"List family members with history here (mother, father, etc.)..."}


Obesity
{"type":"radio","name":"clientFamilyObesity","width":20,"value":"","size":"Normal","validation":"C1","validationMessage":"Please make a selection for this item.","options":"Yes\nNo"}


{"type":"text","name":"clientFamilyObesity_comment","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":"List family members with history here (mother, father, etc.)..."}


Obsessive Compulsive Behavior
{"type":"radio","name":"clientFamilyCompulsiveBehavior","width":20,"value":"","size":"Normal","validation":"C1","validationMessage":"Please make a selection for this item.","options":"Yes\nNo"}


{"type":"text","name":"__generic7","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":"List family members with history here (mother, father, etc.)..."}


Schizophrenia
{"type":"radio","name":"clientFamilySchizophrenia","width":20,"value":"","size":"Normal","validation":"C1","validationMessage":"Please make a selection for this item.","options":"Yes\nNo"}


{"type":"text","name":"clientFamilySchizophrenia_comment","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":"List family members with history here (mother, father, etc.)..."}


Suicide Attempts
{"type":"radio","name":"clientFamilySuicideAttempts","width":20,"value":"","size":"Normal","validation":"C1","validationMessage":"Please make a selection for this item.","options":"Yes\nNo"}


{"type":"text","name":"clientFamilySuicideAttempts_comment","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":"List family members with history here (mother, father, etc.)..."}




Additional Information


1. Are you currently employed?
{"type":"radio","name":"clientCurrentlyEmployed","width":20,"value":"","size":"Normal","validation":"C1","validationMessage":"Please make a selection for this item.","options":"No\nYes"}


How would you describe your job/profession?{"type":"text","name":"clientEmploymentSituation","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":"Bank Teller, Painter, Grocery Clerk, Attorney etc."}


Is there anything stressful about your current work or is there anything about your work that plays a roll in the symptoms/issues you are wanting to improve/heal?
{"type":"textarea","name":"clientEmploymentSituation_comment","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":"Examples: Stress, work with ex, interpersonal issues with my boss etc."}



2. Do you consider yourself to be spiritual or religious?
{"type":"radio","name":"clientSpiritualOrReligious","width":40,"value":"","size":"Normal","validation":"C1","validationMessage":"Please make a selection for this item.","options":"No\nYes\nI prefer not to say"}

If yes, describe your faith or belief:
{"type":"textarea","name":"clientSpiritualOrReligious_comment","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":""}



3. What do you consider to be some of your strengths?
{"type":"textarea","name":"clientStrengths","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","height":80,"placeholder":""}



4. What do you consider to be some of your weaknesses?
{"type":"textarea","name":"clientWeaknesses","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","height":80,"placeholder":""}



Symptoms of Concern

What are the primary area, issues, symptoms or concerns are you wanting to heal/res?{"type":"textarea","name":"clientTherapyGoal","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","height":80,"placeholder":"What would you like help resolving?"}


What is the history surrounding your experience of these symptoms?
{"type":"textarea","name":"__generic","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","height":80,"placeholder":"What is your earliest memory of experiencing them? How long has this been an issue? etc."}



What have you tried previously?
{"type":"textarea","name":"__generic9","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":"If you've done therapy or mental health coaching in the past, what was your experience? What was useful? What did you not like? Did you participate in group programs or purchased products?"}



How does this affect your life and why is resolving this important to you?
{"type":"textarea","name":"__generic","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","height":80,"placeholder":"What does it keep you from doing? How does it hold you back? How are your relationships impacted?"}



How will life be different for you after resolving these issues/symptoms?
{"type":"textarea","name":"__generic11","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":"What will you be doing that you aren't now? How will your experience of life be different? How will your relationships change?"}



On a scale of 1 to 10, how important is it for you to resolve these issues?  
Please Select1 - Not Important2345 - Somewhat Important678 - Very Important910 - Critically Important{"type":"select","name":"__generic12","width":50,"value":"","size":"Normal","validation":"N1","validationMessage":"Please make a selection for this item.","options":"Please Select\n1 - Not Important\n2\n3\n4\n5 - Somewhat Important\n6\n7\n8 - Very Important\n9\n10 - Critically Important"}



Is there anything else you would like your practitioner to know before your consultative diagnostic session?
{"type":"textarea","name":"__generic","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","height":80,"placeholder":""}



Signature & Informed Consent

I have informed about the telehealth practices and I have been given the opportunity to ask questions about services, consultation, and practice. I have acknowledged that the information I have given in the form is accurate and complete. I have understood and given my consent to participate in TeleSession services.

Full Name: {"type":"text","name":"__generic13","width":40,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","placeholder":" As Signed"}

  Date Signed: {"type":"text","name":"signedDate","width":25,"value":"","size":"Normal","validation":"DV","validationMessage":"Please fill in this item.","placeholder":"MM/DD/YYYY"}


Signature
{"type":"signature","name":"__signature","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please enter your signature.","height":200}