Seattle Therapy Alliance
Confidential Individual Patient Intake Form
Date______
Patient Information
Full Legal Name ______
Preferred nickname ______
Date of Birth ______Age ______
GenderIdentity______
Sexual Orientation______
Race______Ethnicity______
Any other identifying information you would like us to know?______
Occupation ______
Student Y N School and program currently attending ______
Mailing Address ______
Email Address ______OK to email you here? Y N
Home Phone ______OK to call you here? Y N
OK to leave a message? Y N
Work Phone ______OK to call you here? Y N
OK to leave a message? Y N
Cell Phone ______OK to call you here? Y N
OK to leave a message? Y N
What is the best phone number to reach you? ______
Emergency Contact Name ______Phone______
Relationship of Emergency Contact______
Counseling Fee
All of our fees are based on a sliding scale between $40-$60. We are unable to go below the $40 fee. We see clients on a weekly basis and do not offer every other week or monthly appointments. We do not take insurance. If you begin counseling at STA, your counselor will have a conversation with you about the counseling fee options.
Are you able to pay between $40-$60 per session for weekly counseling? Y N
In the event STA provides you with a referral, do you have insurance? Y N
If yes, what is your insurance provider? ______
Long Term Counseling Commitment
We believe healing and change most often occur slowly over time. STA offers long-term counseling, and we give priority to clients who are seeking to commit to weekly, long-term work. How sure are you on a scale of 1 to 10 that you are able to commit to weekly therapy for up to one year?
1 2 3 4 5 6 7 8 9 10
not at all likely moderately sure definitely!
How did you hear about STA? Please circle all that apply.
Friend Current STA Client Doctor Internet search/Website
Family member Former STA Client Specify______
Have you been a client at STA before? Y N
Do you have a prior, or current, relationship, however minimal, with any STA intern, extern or staff member? Y N
If yes, please provide as many details as you are comfortable disclosing. This is for us to be able to ensure your anonymity and confidentiality within STA.
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Statement of Need
Please provide a brief description of your reasons for seeking counseling at this time.
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How long have you had these concerns and how have these concerns evolved over time?
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What are your goals for counseling work?
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Please circle any of the following that pertain to you:
Anxiety Depression Fears/Phobias Eating Disorders
Sexual Problems Sexuality Sexual Orientation LGBTQ
Gender Transition Separation/DivorceRelationships Finances Drug/Alcohol Use Infertility Pregnancy/Birth Parenting
Career Choices Stress Anger Self Control
Unhappiness Race/Ethnicity Religion/Spirituality Grief
Suicidal Thoughts Thought Patterns Oppression Self Harm
History of Care
Are you currently under medical care? Y N If yes, please provide some details.
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Information of Personal Physician
Name______Phone______
Are you currently taking prescribed medications? Y N
If yes, please provide some details including a list of any mental health or psychiatric medications you have taken. Please provide dates as close to accurate as possible.
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Does anyone in your family have a history of mental illness? Y N If yes, please provide some information.
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Have you been given a mental health diagnosis? Y N
If yes, please provide the following information:
Diagnosis ______Date of diagnosis ______
Provider ______
Have you been under the care of a psychiatrist, psychologist, or counselor? Y N
If yes, please give the name, date and length of the therapy and briefly explain the nature of the problem that required attention.
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Have you been hospitalized for a mental health related concern? Y N
If yes, please give the date and briefly explain the nature of the problem that required attention.
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Have you ever been in a drug or alcohol treatment program? Y N
If yes, please give the facility, length of time in treatment, and outcome.
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Do you currently drink alcohol? Y N How much?______How often?______
Do you currently use recreational drugs? Y N How often? ______
What substances?______How much? ______
How has your drug/alcohol use impacted your life and relationships? ______
Have you ever been in an eating disorder treatment program? Y N
If yes, please give the facility, length of time in treatment, and outcome.
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Are you currently struggling with an eating disorder or disordered eating? Y N
If yes, what behavior(s)? ______How often? ______
Have you ever considered suicide? Y N
Have you ever attempted suicide? Y N
If yes to either, when? Please provide some details.
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Do you have a history of self-harming behavior? Y / N If yes, please provide some details. ______
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Has there been a change in your activities of daily living? (Appetite, sleep, interest in work/activities, etc)
______
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Please describe your support system.
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Is there anything else you want your therapist to know prior to beginning your treatment? ______
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Scheduling
Seattle Therapy Alliance has a number of counseling times available. We do our best to offer clients an appointment time within their reported availability, as close as possible to your ideal time. Please indicate below the days and times you are available.
Time / Monday / Tuesday / Wednesday / Thursday / Friday / Saturday8am
9am
10a
11:30am
12:30pm
1:30pm
2:30pm
3:30pm
4:30pm
6pm
7pm
8pm
Out of all of the times listed above, what would your ideal appointment times be? ______
While we cannot guarantee an open appointment, we understand that many of our clients want to work with a therapist of a particular social identity.If we can’t pair you with your preference, we will let you know. We will also offer you an appointment with a counselor to give you the option to get started. We’re also happy to provide you with referrals.
With that in mind:
Would you prefer to work with a therapist of color? ______
Would you prefer to work with a LGBTQ+ identified counselor? ______
Would you prefer to work with a particular STA counselor?______
Please return this form to:
Seattle Therapy Alliance
Attn: Grace Rock
OR 200 1st Ave W. Suite 400
Seattle, WA 98119
Thank you for submitting your intake.
We will be in touch with the next steps in the intake process.
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