Leslie Stone M.A., LMFT (Lic.38893) Intake Form Email Personal Information Date * Referred By: First name * Last name * Email Address * Address * City * State * - Select Province/State - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ==================== Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip * Cell Phone * Home Phone Date of Birth * Family Information Status * SingleMarriedPartneredSeparatedDivorcedWidowed Date Children/Step Children? YesNo Names & Ages: Current Problem What brings you to therapy? Be complete as possible. * Why have you decided to come in at this time? Be specific about what has happened that brings you in now. * What would you like to change about yourself to make your situation better? * Education & Work History Usual Occupation * Employer School How Long? Position Highest Degree Completed Medical Information Do you have any medical problems? * YesNo Have you taken any psychiatric medications in the past? * YesNo Psychological History Have you ever been to counseling before? * YesNo Please list non-prescribed substances you currently use/or have used in the past, including alcohol, caffeine, tobacco, amphetamines, cocaine, marijuana, heroin, and/or others: Substance Substance Substance Current Amount & Frequency Current Amount & Frequency Current Amount & Frequency Past Amount & Frequency Past Amount & Frequency Past Amount & Frequency Childhood History List your siblings from oldest to youngest? Names & Ages: Did you have any of these problems with your family? Isolation, too much responsibility, physical abuse, emotional abuse, sexual abuse, alcoholism, other? *
