Gracie LandesLMFT, CST | ph:917-238-0170 |
New York State Marriage and Family Therapist #7, AASECT Certified Sex Therapist
Welcome to my practice. I look forward to meeting you soon.Meanwhile, thanks for filling out this form, as well as the Patient Registration at TherapyAppointment.com, which asks different questions from these. While not every question on the form may be equally important to you, thanks for giving it your best effort:the questions are designed to get your therapy off the best possible start.
Please email this form to me at least one full day before we meet.
name:
date of birth:
phone:
email:
How do you prefer to be contacted if I need to reach you: phone? email? text message?
Will someone be attending therapy with you? If, so what is their name and relationship to you?
(If that person will attend therapy with you, please have them fill out their own copy of this form).
Who referred you: friend? website? referral service? which one?
To avoid awkwardness later, how will you be paying?:
- private payment (not using insurance)?
- Insurance? What company handles your mental health benefits?
- If your mental health benefits are with Aetna, Empire Blue Cross Blue Shield or TriCare:
What is your co-payment amount? $
Do you have a deductible? What is it?
-If yourmental health benefits are with any other insurance company than those listed above:
- Do you have out-of-network benefits?
- What percentage will you be reimbursed at?
- Do you have a deductible? What is it?
How do you learn best (reading, listening and talking, doing and trying out new things)?
What prompted you to come in at this particular time, and what would you like to accomplish in this therapy?
How will you know you therapy has succeeded for you, ie: What will be happening in your life?
What will you be doing differently?
What do you think I should do to help you get there?
Clients often notice that between making an appointment for therapy and the first session, things already seem different for them. Have you noticed some changes in the area you came to therapy to work on since making the appointment?
If so, are those changes ones you would like to see continue?
What have you already done to change the situation(s)?
What happened as a result of your efforts?
How did people around you react?
When did the situationyou would like to change first occur? What was going on in your life at that time?
If there is more than one situation, which do you recall as having developed first?
Under what circumstances does the situation occur? What circumstances intensify the situation(s)?
Where and when does the situation temporarily get better or improve?
Who is available to help offer you solutions (friends, coworkers, family members) ?:
If your reason for seeking counseling involves another person or people, will they be willing to join you for at least some sessions? Are you willing to have them join you?
What other resources are available to you to help you solve this problem (community resources, other helpers, skills you already possess, etc.)?
Please indicate the extent to which you agree or disagree with each of the statements that follow. In each case, make your choice in terms of how you feel right now, not what you have felt in the past or would like to feel. For all the statements that refer to your “problem”, answer in terms the problem that brought you to therapy, and “here” refers to therapy. For each item please put an X directly to the right of the one that applies.
There are FIVE possible responses to each of the items:
1 Strongly Disagree 2 Disagree 3 Undecided 4 Agree 5 Strongly Agree
1. I am doing something about the problems that had been bothering me.
1 Strongly Disagree 2 Disagree 3 Undecided 4 Agree 5 Strongly Agree
2. I wish I had more ideas on how to solve the problem.
1 Strongly Disagree 2 Disagree 3 Undecided 4 Agree 5 Strongly Agree
3. I really want to change.
1 Strongly Disagree 2 Disagree 3 Undecided 4 Agree 5 Strongly Agree
4. Even though I'm not always successful in changing, I am at least working on my problem.
1 Strongly Disagree 2 Disagree 3 Undecided 4 Agree 5 Strongly Agree
5. I'm not the problem one. It doesn't make much sense for me to be here.
1 Strongly Disagree 2 Disagree 3 Undecided 4 Agree 5 Strongly Agree
6. I have been successful in working on my problem but I'm not sure I can keep up the effort on my own.
1 Strongly Disagree 2 Disagree 3 Undecided 4 Agree 5 Strongly Agree
What are the traits, qualities and characteristics that describe you at your very best?
What were you doing when you or someone else noticed these things about you?
What are your interests, skills, talents, and hobbies?
What is interesting or valuable to you about them?
What makes you happy or gives you satisfaction?
What is your occupation, or, how do you support yourself, or spend your time?
What do you want me to understand about your ethnic, cultural or spiritual affiliations?
Are there any medical or psychological conditions (diabetes or depression for example) that run in your family?
Are you able to eat and sleep well? If not, what do you struggle with?
For the next several questions on sexuality, if you are not here for a couple/sexual issue, tell me what you think may be relevant to your therapy:
If you are sexually active, do you have a satisfactory sex life?
If not, what do you struggle with sexually?
What should I know about your sexual history and preferences?
What significance (meaning) does the problem have with respect to your own sexual functioning?
What happened the last time you had sex?
Was it a positive experience?
What factors contributed to that perception?
Under what circumstances have does your sexuality work the way you want it to? (with which people, situations, locations, time of the day, thoughts, images, feelings, and sensations):
How does the problem affect your own or a partner’s sexual functioning?
Do you or someone close to you drink or use recreational drugs?
If so, what do you/they or you use: how much and how often?
If so, how does the other person’s use affect you?
Have you been in therapy before? What for?
Did it help? If so, what was most helpful to you?
What there anything that was not helpful or didn’t work for you? Why?
Anything else you’d like to tell me? Please say as much or as little as you’d like:
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GRACIE LANDES INTAKE FORM (07-2014)