Intake Forms

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Couples Counseling Initial Intake Form

Trinity Psych Wellness

Couples Counseling Initial Intake

Conatct Information

Your First Name

Your Last Name

Your Email

Date of Birth (day/month/year)

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Your Phone/Cell

Date / Time

Partner's First Name

Partner''s Last Name

Emergency Contact Person:

extremely unhappy extremely happy
0	1	2	3	4	5	6	7	8	9	10

extremely unpleasant extremely pleasant
0	1	2	3	4	5	6	7	8	9	10

extremely unpleasant extremely pleasant
0	1	2	3	4	5	6	7	8	9	10

extremely unpleasant extremely pleasant
0	1	2	3	4	5	6	7	8	9	10

extremely unpleasant extremely pleasant
0	1	2	3	4	5	6	7	8	9	10

Spiritual Intake Form (#16)

Trinity Psych Wellness

SPIRITUAL INTAKE FORM

For Therapy and Empowerment

First Name

Last Name

Today's Date

Date of Birth (Day/Month/year)

Section One

Personal and Spiritual Background

What is your religious or spiritual background (if any)?

Do you currently follow any spiritual or religious practices? If yes, please describe.

What does spirituality mean to you personally?

Are there any particular spiritual or religious beliefs that are especially important to you?

Do you participate in any community, group, or religious gatherings?

How has your spirituality or religion influenced your life decisions, relationships, or sense of purpose?

Section Two

Current Spiritual Practices

Do you engage in any of the following practices? (Check all that apply)

Meditation

Prayer

Mindfulness

Journaling

Rituals (e.g., seasonal, praying, fasting, or cultural)

Any other practices not included above?

How often do you engage in the above practices?

Do you have a personal spiritual routine or discipline?

Are you interested in exploring or developing new spiritual practices? If yes what are you interested in?

Section Three

Spiritual Challenges and Growth

Are there any current challenges you are facing in your spiritual journey?

Have you experienced any major life events that have influenced your spiritual path?

Do you feel any conflicts between your spiritual beliefs and other aspects of your life (e.g., work, family, relationships)

What areas of your life do you feel need healing or empowerment?

Section Four

Therapeutic Goals and Empowerment

What are your goals for therapy or empowerment work?

How would you like your spirituality to be integrated into your therapy sessions?

What would spiritual empowerment look like for you?

Section Five

Additional Information

Is there anything else about your spiritual or religious beliefs that you think would be helpful for me to know?

Are there any spiritual or cultural sensitivities I should be aware of?

Release of Information

TRINITY PSYCH WELLNESS

Authorization for Release of Health Information

First Name

Last Name

Date of Birth: Day/Month/Year

Your Email

The above named person must indicate when this authorization permission is to expire:

The person named above is currently OR has been previously a patient of:

Address of Provider / Facility named above:

Address Line 1

Address Line 2

City

State

Zip Code

Country

Provider's Phone

Provider's Fax

The patient/client above hereby authorizes

authorizes name provider to:

Request health information

Send health information

Discuss health information

Name of Person, Provider, or Facility Address to release information.

Provider's Phone

Provider's Fax

SCOPE

Of patient/client information

All information regarding assessment, diagnosis, and treatment of patient’s condition, concern, or disease (specify details as needed):

Start Date

End Date

Any other comments to communicate place here.

AUTHORIZATION

Name of Patient or Authorized Representative

First Name

Last Name

Signature of Patient or Authorized Representative

Sign Here

Today's Date - select

Signature of Witness

Sign Here

Today's Date - select

If not signed by the patient, indicate relationship of authorizing person to patient:

Additional Authorization

Certain information is covered by additional protection and requires specific authorization. To authorize release or discussion of the following type of information, the person named above must initial and date each item. If an item is not initialed and dated, the information, if such information exists, cannot be released or discussed.
Select information types that apply and specify the date range of additional authorization release period.

I authorize release or discussion of the following type of information: (Select all that apply)

Alcohol or Drug Use/Abuse Treatment

Mental Health Treatment

HIV Status or Treatment

FROM Date

TO Date

PERSONAL RIGHTS

The above-named person has the following rights:

This authorization is effective for the above requested and authorized health care information only. You may ask for and receive a copy of this authorization form.

This authorization will expire on the date you indicated above. Additionally, you may revoke this authorization at any time by submitting a written request to this clinic or caretaker. Your revocation will be honored except to the extent that is been acted upon in good faith while in force.

You have the right to inspect the information you are authorizing to be re-released. This and other specific rights regarding the handling of your health information are outlined in our Privacy Practices document.

The information you are authorizing to be released could be re-released or disclosed by the recipient. Such additional disclosures or releases may not be prohibited by law. We are not responsible for the actions of others who may be provided with information released as a result of this authorization.

You may refuse to sign this authorization. Such refusal will not affect your ability to obtain treatment except to the extent that the information being requested may assist your health care provider in determining appropriate treatment. Your refusal to sign this authorization will not affect your eligibility for benefits.

Resources

Important Contact Numbers

Behavioral Health Emergency Dial 988

EMERGENCY SERVICES #988

For a behavioral mental health emergency, client and/or family can dial 988.
This is now the three-digit phone number code that routes callers to the 988 Suicide & Crisis Lifeline.
For Medical Police & Fire call 911

CRISIS LINES

Empact Crises Line: 480-784-1500 or 1-800-273-8255
Maricopa Crisis Line: 602-222-9444 or 1-800-631-1314
Teens Lifeline: 602-248-8336
MIND: 24/7 844-646-3247
Warm Line: 602-347-1100

NATIONAL CRISIS LINES

National Domestic Violence Hotline: 1-800-799-7233
National Suicide Prevention Lifeline: 1-800-273-8255
National Teen Dating Abuse Helpline: 1-866-331-9474
Rape, Abuse & Incest National Network: 1-800-656-4673
Rescue America (trafficking): 713-322-8000

Intake Forms

Please complete the form to the best of your ability.

Adult Registration Intake Form

Suicide Risk Assessment

Past Medical History:

Women Only

Personal and Family Medical History:

Past Psychiatric History:

Past Psychiatric Medications:

Antidepressants

Your Exercise Level

Family Psychiatric History:

Substance Use:

Family Background and Childhood History:

Education & Occupational History:

Relationship History and Current Family:

Legal history:

Spiritual History:

TRINITY PSYCH WELLNESS

Person Completing This Form

CHILD'S INFORMATION

CONTACT INFORMATION

1. Contact

2. Contact

3. Emergency Contact

Financial Contact

FAMILY HISTORY

RELATED TO PARENT'S DIVORCE

HOUSEHOLD MEMBERS

MEDICAL HISTORY

EDUCATION HISTORY

ACADEMIC CONCERNS

Early Development

Substances used during pregnancy

EARLY BEHAVIOR

EARLY EXPERIENCES

CHILD'S TRAITS

Problem Areas

FAMILY TRAITS

Social Media and Technology

REVIEW

Trinity Psych Wellness

Conatct Information

Thank You

Trinity Psych Wellness

SPIRITUAL INTAKE FORM

Section One

Section Two

Section Three

Section Four

Section Five

Trinity Psych Wellness

Over the last 2 weeks, how often have you been bothered by any of the following problems?

Trinity Psych Wellness

Over the last 2 weeks, how often have you been bothered by any of the following problems?

Trinity Psych Wellness

Adult ADHD Self-Report Scale

Self-Report:

TRINITY PSYCH WELLNESS

TRINITY PSYCH WELLNESS

Authorization for Release of Health Information

SCOPE

AUTHORIZATION

Additional Authorization

PERSONAL RIGHTS

TRINITY PSYCH WELLNESS

Tele Mental Health Informed Consent.Please review and indicate you have understood each content section.

TRINITY PSYCH WELLNESS

Resources

Important Contact Numbers

Behavioral Health Emergency Dial 988

Tele Mental Health Informed Consent.
Please review and indicate you have understood each content section.