Therapy UnPlugged Intake Form – Connections Unplugged

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Intake Form

I am completing this Therapy UnPlugged Intake Form for:*
Age Consent of a Minor Patient 17 years and younger or a Disabled Patient with a Healthcare Proxy*
By checking this box I consent that I am the legal guardian of the patient seeking treatment and that I am filling this information out on behalf of the patient.
Relationship of person filling out intake form for minor patient*
Define "other" relationship of person filling out intake form for minor patient*
Guardian's Name*
First Last
Guardian's Phone Number*
Patient's Name*
First Last
Patient's Date of Birth*
Please note that we do not see patients under the age of 8 years or over the age of 64 years.
MM
DD
YYYY
Patient's Gender*
Please define "Other" Gender*
Patient's Address*
Street Address Address Line 2 City State ZIP Code
Patient's Cell Phone Number*
Best Contact E-mail Address*
Email & Appointment Reminder Communication Consent*

I agree to receive practice updates and new services offered.
How were you referred to Therapy UnPlugged?*
- Primary Care Physician
- Medical Specialist (GI, Neurologist, etc)
- Inpatient Psychiatric Facility (PHP, IOP, Baker Act Facility, Residential Program)
- Friend/Family
- School
- Online Search
- Insurance Provider List
- Legal Referral (lawyer, probation, DJJ, etc)
- Other
Name of Referring Family/Friend*
First Last
Please state "other" referral source*
Name of Referral Source*
First Last
Are you currently seeing a psychiatrist and/or therapist or have seen one in the past 6 months?*
Name of Current or Most Recent Psychiatric Treatment Provider*
First Last
Phone*
What type of therapy best fits your situation?*
Please check all that apply.
- Individual Therapy
- Parent/Child Relationship Therapy
- Couples Therapy
- Family Therapy
- I am not sure
Have you ever been diagnosed with the following?*
If filling out for a minor child, please check any diagnoses they have received in previous treatment. Please bring copies of any evaluations or past medical record to the initial appointment at our office. *PLEASE NOTE THAT OUR FACILITY DOES NOT SPECIALIZE OR TREAT THE DISORDERS WITH (*) SYMBOL.
- ADD/ADHD
- Anxiety Disorder
- Autism
- Depression
- Bipolar Disorder
- Insomnia
- Eating Disorders*
- Mood Disorder
- OCD
- Oppositional Defiant Disorder/Conduct Disorder*
- Personality Disorders*
- PTSD
- Schizoaffective Disorder
- Schizophrenia
- Substance Abuse*
- None
Reason for Visit*
Please describe, in detail, the reason you are seeking care. Include any symptoms and when they started.

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