Susan M. Hall, D.Min., LMHC   

                                 200 First Ave. West, Seattle, WA 98119

Intake Form

Date  ______  Last Name _______________________  First Name _______________________

Address  _____________________________________________________________________

City ___________________________  State  _____________  Zip ____________________

Email Address________________________________________________________________

*Home Phone ___________________________  Work Phone ___________________________

Sex (M/F) _____________________  DOB  __________  SS# _________________________

Is it acceptable to contact you at home?  Y / N 

If "no" then how can I contact you? _________________________________________________

Are you currently under medical care?  Y / N

If yes, then please explain/describe.  _________________________________________________

____________________________________________________________________________________________________________________________________________________________

Name of Personal Physician & Phone Number: ________________________________________

Are you currently taking prescribed medications?  Y / N

If yes, then please explain/describe. _________________________________________________

______________________________________________________________________________

List any psychiatric/mental health medications you have taken. ___________________________

______________________________________________________________________________

Have you been under the care of a psychiatrist, psychologist, or counselor?  Y / N

If yes, please give the name, date, and location of the therapy and briefly explain the nature of the problem which required attention. __________________________________________________

______________________________________________________________________________

Please circle any of the following struggles that pertain to you:

Anxiety                         Depression                    Fears/Phobias               Eating Disorders

Sexual Problems            Suicidal Thoughts          Separation/Divorce        Relationships

Finances                       Drug/Alcohol Use         Career Choices             Anger

Self-Control                  Unhappiness                 Insomnia                       Religious Matters

Work/Stress                  Health Problems            Cutting/Self-Mutilation    Thought Patterns

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