Client In-Take Form- Self Referred or Community Agency Referred

California Psychological Institute
1470 West Herndon Avenue
Fresno, CA  93711

CLIENT'S CONTACT INFORMATION

Do you have health Insurance Information for mental health services? 

CLIENT'S PERSONAL DATA

Please list all medications you are currently taking, including over-the-counter and herbal.

TYPES OF HELP DESIRED

Have you had past Counseling or Psychotherapy?  If yes, please respond below: 

Have you had any psychiatric hospital admissions? 

Have you previously received, or are you currently receiving any additional services? Ex: TBS, IEP, Wrap services, EPU  etc:

Thank you for your cooperation.  This information will be helpful in planning services for you.  All information on this form is confidential and will not be released without your prior written approval.

Symptoms Checklist

 


 

Responsible Party :______________________________________________________________

Date:__________________________

Please print out this page after you have filled it out, then sign it and bring it with you on your first visit.