Intake Survey

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1. Date of first counseling session:

	MM		DD		YYYY
*	Date of first counseling session: * Month	/	Day	/	Year

2. Your birthdate

	MM		DD		YYYY
*	Your birthdate * Month	/	Day	/	Year

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3. Please complete the following contact information (Note: If you would like to receive text messages on your cell phone, please include the name of your cell phone carrier):

Please complete the following contact information (Note: If you would like to receive text messages on your cell phone, please include the name of your cell phone carrier): Name:
Address:
Address 2:
City/Town:
State:
ZIP:
Email Address:
Phone Number:

4. Enter any additional contact information or special calling, mailing, or e-mailing instructions here. (For example, you might ask Dr. Erwin to leave her first name only when leaving a message on your home phone.):

Enter any additional contact information or special calling, mailing, or e-mailing instructions here. (For example, you might ask Dr. Erwin to leave her first name only when leaving a message on your home phone.):

5. Insurance Information:

Note: All insurance clients are required to make a $45 deposit for each session. You will then receive a Super Bill that contains all of the information you need to submit a claim to your insurance company. THIS POLICY DOES NOT APPLY TO CLIENTS RECEIVING COUNSELING SERVICES THROUGH THEIR EMPLOYEE ASSISTANCE PROGRAM (EAP).

Insurance Information: Note: All insurance clients are required to make a $45 deposit for each session. You will then receive a Super Bill that contains all of the information you need to submit a claim to your insurance company. THIS POLICY DOES NOT APPLY TO CLIENTS RECEIVING COUNSELING SERVICES THROUGH THEIR EMPLOYEE ASSISTANCE PROGRAM (EAP). Name of insurance carrier:
Name of policy holder:
Subscriber ID Number:
Group Number:
Phone Number for Providers:

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6. If there is an emergency during your work with Dr. Erwin, or she becomes concerned about your personal safety, she is required by law and by the rules of her profession to contact someone close to you—perhaps a relative, spouse, or close friend. Dr. Erwin is also required to contact this person, or the authorities, if she becomes concerned about your harming someone else. Please provide the name and contact information of your chosen contact person in the blanks provided:

If there is an emergency during your work with Dr. Erwin, or she becomes concerned about your personal safety, she is required by law and by the rules of her profession to contact someone close to you—perhaps a relative, spouse, or close friend. Dr. Erwin is also required to contact this person, or the authorities, if she becomes concerned about your harming someone else. Please provide the name and contact information of your chosen contact person in the blanks provided: Name:
Address:
Address 2:
City/Town:
State:
ZIP:
Email Address:
Phone Number:

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7. It may be beneficial for Dr. Erwin to confer with your primary care physician with regard to your psychotherapy or to discuss any medical problems for which you are receiving treatment. Please check one of the following:

It may be beneficial for Dr. Erwin to confer with your primary care physician with regard to your psychotherapy or to discuss any medical problems for which you are receiving treatment. Please check one of the following: You ARE authorized to contact my primary care physician whose name and address are shown below to discuss the treatment that I am receiving while under your care and to obtain information concerning my medical diagnosis and treatment.

You ARE NOT authorized to contact my primary care physician with regard to the treatment that I am receiving while under your care or to obtain information concerning my medical diagnosis and treatment. I am providing you with the name and address of my primary care physician only for your records:

8. Please provide your primary physician's contact information. (Leave blank if you do not have a primary physician.)

Please provide your primary physician's contact information. (Leave blank if you do not have a primary physician.) Name:
Company:
Address:
Address 2:
City/Town:
State:
ZIP:
Phone Number:

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9. It may be beneficial for Dr. Erwin to confer with your previous psychotherapists with regard to your psychotherapy. Please initial ONE of the following:

It may be beneficial for Dr. Erwin to confer with your previous psychotherapists with regard to your psychotherapy. Please initial ONE of the following: You ARE authorized to contact my previous psychotherapist(s) whose name(s) and address(es) are shown below to discuss the treatment that I am receiving while under your care and to obtain information concerning my previous diagnosis and treatment.

You ARE NOT authorized to contact my psychotherapist(s) with regard to the treatment that I am receiving while under your care or to obtain information concerning my previous diagnosis and treatment. I am providing you with the name and address of my previous psychotherapist(s) only for your records.

Please provide the name and contact information for any psychotherapists you have seen in the past.

10. Use this space to provide information about important individuals in your life you'd like Dr. Erwin to know about.

Use this space to provide information about important individuals in your life you'd like Dr. Erwin to know about. Name:
Age:
Relationship:
Name:
Age:
Relationship:
Name:
Age:
Relationship:
Name:
Age:
Relationship:
Name:
Age:
Relationship:
Name:
Age:
Relationship:
Name:
Age:
Relationship:

Intake

1. Demographics

*1. Date of first counseling session: