Tell me about yourself.
BEING FREE INTAKE QUESTIONNAIRE

Please provide the following information for our records. Leave blank any questions you would rather not answer, or would prefer to discuss with your therapist Information you provide here is held to the same standards of confidentiality as our therapy.

Are you currently receiving psychiatric services professional counseling or psychotherapy elsewhere?
Have you had previous psychotherapy?

If yes, previous therapist's name:

Are you currently taking prescribed psychiatric medication (antidepressants or other)?

If yes, please list:

Prescribed by:

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