Email Form

DBT Center of San Diego
First Session Intake Form

Date of First Session Therapist

This information needed for confidential ID numbers for all people who will participate in the therapy (e.g., the primary patient, the spouse or partner, and family members who will participate)

	Social Security Number	Birth Date

primary patient	(last four digits only)	Month Day Year
person #2		Month Day Year
person #3		Month Day Year

Gender
Home Address	, Unit#
	zip
Home Phone Number	() - private voice mail (detailed messages OK?)
Mobile Phone Number	() - private voice mail
Email Address	private account
Current Employment	Work Phone Number () - private voice mail

How did you find out about our clinic?

Demographic Information

Primary ethnic background	Other
More than one ethnic group?
Current religion	Other
	I attend church or other services
Highest education completed
Are you currently in school?
Relationship status

Emergency Contacts

First Name	Relationship to you	Phone Number 1	Phone Number 2
		() -	() -
		() -	() -

Treatment History
Previous or current counseling or psychotherapy?
Medications for a psychological condition?
                          How many currently?
Diagnoses
major depression
dysthymia
bipolar disorder
alcohol abuse
schizophrenia
schizoaffective
borderline personality
dissociative identity
bulimia
binge eating disorder
anorexia
body dysmorphic disorder
social anxiety disorder
generalized anxiety disorder
panic disorder
agoraphobia
post-traumatic stress disorder
obsessive-compulsive disorder
Other diagnoses

How many hours do you spend outside of your house on average:
weekdays
weekend days

Have you ever tried to kill yourself (even if you did not fully want to die)?
Have you ever harmed yourself on purpose (even if you did not intend to die)?

Mental Health Insurance
Treatment fees are to be paid by the client and you may seek partial reimbursement from your insurance company. Let us know if you would like us to check if you can get reimbursed for services you pay for at DBTCSD. If so, we are willing to submit your insurance reimbursement paperwork.

Will you seek reimbursement from your insurance company?
  If so, provide the following information:
      Insurance Company Name
      Policy Number
Any special instructions for how we prepare your monthly summary statement of services, fees, and payments?


Please call us if you would you like DBTCSD to help you obtain reimbursement from your insurance company

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