Client Intake Form

Tiffany Thomas, M.A., CADC-II, LMFT

Licensed Marriage & Family Therapist #122564

(818)533-8672 | tiffanythomastherapy@gmail.com

11712 Moorpark St, Suite 111, Studio City, CA 91604

GENERAL INFORMATION
Client's Name

First

Last
Birth Date
Address
Main phone
Email Address
You have my permission to contact me on my

Phone Email
Referral source: (how did you hear about me)?
EMPLOYMENT
Occupation
Length of time there
Responsibilities
Do you like your work?

Yes No Sort of
PERSONAL / FAMILY INFORMATION
Marital Status

Single Living Together Married Partner Separated Divorced
Brief relationship history:
Names/ages of children:
Parents:

Both alive Father deceased Mother deceased
Siblings/ages:
Emergency contact:
Emergency contact Phone Number:
Emergency contact relationship to you:
FINANCIAL INFORMATION
Preferred Payment:

Cash Check Credit Card Zelle
I will need a monthly claim form for insurance reimbursement

Yes No
Have you previously been in psychotherapy or counseling?
If so, for how long? When? Why?
What were the results?
Please list any previous or current medications you have taken for psychological purposes:
Please list all prescription medications you are currently taking:
If you have had difficulties with any of the following, either current or past, please explain:
Alcohol, drug, or tobacco dependence or frequent use?
Eating disorder(s)
Other addictive or compulsive behavior(s)?
Depression or suicidal thoughts/attempts?
Anxiety or panic attacks?
Major illness, surgery or physical problems?
Anger issues, domestic violence (current or childhood)?
Marital, relationship, or family problems (current or childhood)?
Learning disabilities/problems or “ADD/ADHD?
List stressful situations in your life (accident, hospitalization, relationships, traumatic events)
What brings you into therapy at this time?
What do you hope to achieve from therapy?
Other useful information to assist in counseling:

Client Intake Form

GENERAL INFORMATION

EMPLOYMENT

PERSONAL / FAMILY INFORMATION

FINANCIAL INFORMATION