DBT Center of San Diego
First Session Intake Form
All people who will participate in the therapy need to send us this information such as the spouse or partner, or family members of of the primary patient.
Date of First Session
Jan
Feb
Mar
Apr
May
Jun
July
Aug
Sep
Oct
Nov
Dec
1
2
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5
6
7
8
9
10
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23
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27
28
29
30
31
Name of therapist
Sue Boyd
Lisa Campbell
Milton Brown
Other
Social Security Number
(last four digits only)(needed for your confidential ID number)
Gender
female
male
Date of Birth
Month
Jan
Feb
Mar
Apr
May
Jun
July
Aug
Sep
Oct
Nov
Dec
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
Home Address
Street
Road
Avenue
Blvd
Circle
Lane
Place
, Unit#
California
Alabama
Alaska
Arizona
Arkansas
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachussetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
zip
Home Phone Number
(
)
-
private voice mail
No
Yes
(detailed messages OK?)
Mobile Phone Number
(
)
-
private voice mail
No
Yes
Email Address
private account
No
Yes
Current Employment
No
Yes
Work Phone Number (
)
-
private voice mail
No
Yes
How did you find out about our clinic?
therapist or clinic
Marsha Linehan clinic
another client
this web site
a research study
San Diego Psychological Association
TARA
National Education Alliance-BPD
BehavioralTech
other
Demographic Information
Primary ethnic background
Latino
White/Caucasian
Native American or Alaska Native
Black or African American
Chinese American
Japanese American
Korean American
Other Asian American
East Indian
Middle Eastern
Native Hawaiian
Other Pacific Islander
Other
Other
More than one ethnic group?
No
Yes
Current religion
None
Christianity
Protestantism
Catholicism
Judaism
Islam
Hinduism
Buddhism
Agnosticism
Atheism
Other
Other
I attend church or other services
No
Yes
Highest education completed
eight grade or less
some high school
GED
high school graduate
technical school graduate
business school graduate
college graduate
masters degree
doctoral degree
Are you currently in school?
No
high school
technical school graduate
business school graduate
college undergraduate
graduate school
Relationship status
single
married - living with spouse
married - living apart
in a romantic relationship - living with partner
in a romantic relationship - living apart
Emergency Contacts
First Name
Relationship to you
Phone Number
spouse or partner
parent
sister or brother
child
other family
friend
other
(
)
-
spouse or partner
parent
sister or brother
child
other family
friend
other
(
)
-
Treatment History
never
yes - currently
yes - but not currently
Previous or current counseling or psychotherapy?
never
yes - currently
yes - but not currently
Medications for a psychological condition?
How many currently?
Diagnoses
never
now
in the past
major depression
never
now
in the past
dysthymia
never
now
in the past
bipolar disorder
never
now
in the past
alcohol abuse
never
now
in the past
schizophrenia
never
now
in the past
schizoaffective
never
now
in the past
borderline personality
never
now
in the past
dissociative identity
never
now
in the past
bulimia
never
now
in the past
binge eating disorder
never
now
in the past
anorexia
never
now
in the past
body dysmorphic disorder
never
now
in the past
social anxiety disorder
never
now
in the past
generalized anxiety disorder
never
now
in the past
panic disorder
never
now
in the past
agoraphobia
never
now
in the past
post-traumatic stress disorder
never
now
in the past
obsessive-compulsive disorder
Other diagnoses
How many hours do you spend outside of your house on average:
weekdays
weekend days
No
Yes
Have you ever tried to kill yourself (even if you did not fully want to die)?
No
Yes
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.
No
Yes
Will you seek reimbursement from your insurance company?
No
Yes
Would you like DBTCSD to handle your reimbursement?
If so, provide the following information:
Insurance Company Name
Policy Number
Please enter your Email address again:
Anything Else?