Clincial Forensics Intake Form

CFA INTAKE FORM

Please complete this intake form, so that we can enroll you into services with Clinical and Forensic Associates. Be sure to answer all questions, upload a copy of your driver's license, insurance card (front and back) and along with the electronic payment authorization form and confidentiality forms. All information provided here is protected as confidential information.

First Name *

Last Name *

Email *

Phone *

Date of birth

Address

Name of Parent/Guardian (If under 18 years)

Gender

Preferred Pronouns

Marital Status

Referred by (If Any)

Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc.)?

If so, list the name of the previous therapist or practitioner

Are you currently taking any prescription medication?

Have you ever been prescribed psychiatric medication?

Please provide a list of all prescription and/or psychiatric medication and dates

General Health and Mental Health Information

These questions provide general information for our therapists to assist in your care.

How would you rate your current physical health?

Please list any specific health problems you are currently experiencing.

How would you rate your current sleeping habits?

How many times per week do you generally exercise?

What types of exercise do you participate in?

Please list any difficulties you experience with your appetite or eating patterns.

Are you currently experiencing overwhelming sadness, grief or depression?

If yes, how long?

Are you currently experiencing anxiety, panic attacks or have any phobias?

If yes, when did you begin experiencing this?

Are you currently experiencing any chronic pain?

If yes, please describe.

Do you drink alcohol more than once a week?

How often do you engage recreational drug use?

What significant life changes or stressful events have you experienced recently?

FAMILY MENTAL HEALTH HISTORY

In the section below identify if there is a family history of any of the following. If yes, please indicate the family member’s relationship to you in the space provided (father, grandmother, uncle, etc.).

Please list the disorder and indicate the family member’s relationship to you in the space provided (father, grandmother, uncle, etc.).

ADDITIONAL INFORMATION

Please share the following information with our team.

Are you currently employed?

If yes, what is your current employment status?

Do you enjoy your work? Is there anything stressful about your current work?

Do you consider yourself to be spiritual or religious?

If yes, describe your faith or belief.

What do you consider to be some of your strengths?

What are some areas you would like to improve on or have help with?

What would you like to accomplish out of your time in therapy?

Please upload the front of driver's license, front and back of insurance card, signed electronic payment authorization, and confidentiality policy.

Driver's License (Front) *

Insurance Card (Front) *

Insurance Card (Back) *

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Clinical Forensics & Associates

Terms & Conditions | Privacy Policy | Earnings Disclaimer Copyright 2025 [email protected] , All Rights Reserved

Terms & Conditions | Privacy Policy | Earnings Disclaimer
Copyright 2025 [email protected] , All Rights Reserved