New Patient Intake Form - Online | Dr. Nahal Delpassand

What is/are the reason(s) you are seeking therapy today?

If yes, please describe the incident.

Please describe what you hope to accomplish in this therapy or what you hope will be different in your life as a result of attending therapy.

How long has the problem been present?

What solutions to the problem have you tried, and what were the results?

If OTHER (Please specify):

Who is your primary care physician and your primary clinic?

Who else do you regularly see as part of your routine health care?

List any significant health problems, past or present, including surgeries and/or illnesses with the corresponding dates.

If yes, please list:

If yes, please list and describe the reaction.

List other therapy or counseling you have received in the past or are receiving now:

If yes, when and where?

If yes, please give details

Have you ever felt you should cut down on your drinking or drug use? Have people annoyed you by criticizing your drinking or drug use? Have you ever felt bad or guilty about your drinking or drug use?

Have you ever had a drink or used drugs as an eye-opener first thing in the morning to steady your nerves, get rid of a hangover, or to get the day started?

Have you ever had treatment for any type of alcohol or substance use?

What has helped you manage or endure your current problem?

Please describe the people in your life that currently play a supportive, influential, or friendship role.

What interests or passions give meaning to your life?

If yes, please explain:

What aspects of your culture, heritage, or ethnicity would you like your therapist to be aware of?

Name

Age

Relation to you

Other

If yes, please tell me about it here:

Presenting Problem

Mental Health & Medical History

Link to downloadable/printable Release Information form.

Substance Use

Family Information

Signature and Date

I acknowledge that the information on this form is accurate to the best of my knowledge, and that I will inform Dr. Delpassand of any changes in my personal circumstances including, symptoms experienced, suicidal thoughts and substance use.

PLEASE PRINT FORM BEFORE SUBMITTING