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Intake Screening Form

Please fill out the below information

After completing this form, please contact the practice directly for appointment scheduling and availability. 518-490-6429


PERSONAL INFO

Date of Birth
Month
Day
Year
Marital Status

GENERAL INFO

Please select which type of counseling you are seeking
Do you have any legal issues? If yes, please explain below.

CURRENT SYMPTOM CHECKLIST

Rate intensity of symptoms currently present

Depressed mood
Appetite disturbance
Sleep disturbance
Paranoia
Self-mutilation
Poor concentration
Irritability
Anxiety
Obsessions / compulsions
Anorexia
Hallucinations
Conduct problems
Sexual dysfunction
Hopelessness
Social isolation
Emotional trauma victim
Binging / purging
Guilt
Elevated mood
Fatigue / low energy
Hyperactivity
Mood swings
Emotionality
Panic attacks
Physical trauma victim
Paranoia
Aggressive behaviors
Oppositional behavior
Grief
Substance abuse
Suicidal Ideation
Worthlessness
Sexual trauma victim
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