Stacey S Intake

INTAKE ASSESSMENT

Patient:
Date of Birth:
Intake Date:
Reason for Seeking Therapy:   	

Presenting Symptoms: 
[textarea name="variable_1" default="sample text"]   	
Presenting Problem History: 
[textarea name="variable_1" default="sample text"]   	
Family History: 
[textarea name="variable_1" default="sample text"]   	
Education and Occupational History: 
[textarea name="variable_1" default="sample text"]    	
Medical Problems: 
[textarea name="variable_1" default="sample text"]   	
Current Prescription Medications: 
[textarea name="variable_1" default="sample text"]
Alcohol, Nicotine, and Drug History: 
[textarea name="variable_1" default="sample text"]  	
Mental Health Treatment History: 
[textarea name="variable_1" default="sample text"] 
Legal History: 
[textarea name="variable_1" default="sample text"]  	
Spiritual Life: 
[textarea name="variable_1" default="sample text"]