top of page
Vanessa Mangual-Greenwald, Psychosomatic Practioner
Book an Appointment
Home
Services
Intake Form
Contact
Blog
More
Use tab to navigate through the menu items.
Intake Form
Personal Information:
First Name
Last Name
Email
Phone
Address
Date of Birth
Preferred Prounouns
Primary Language
Race/Ethnicy
Name of Parent/Guardian if under 18
Referred by
Relationship to person referred by.
Do you live alone?
Are you employed?
What is your current employment situation?
Do you describe yourself as someone with spiritual or religious beliefs? Is yes, please describe.
Emergency Contact Information:
Contact First Name
Contact Last Name
Contact Phone Number
Relationship to contact:
General Health and Mental Health History:
Please fill out what you are comfortable sharing.
How would you describe your health? List any previous surgeries or hospitalizations.
Please share any concerns you may be experiencing.
Are you experiencing any changes in your appetite? If so, please explain.
Are you currently feeling any overwhelming sense of sadness, grief, and/or depression? Please describe and share how long you have been feeling this way.
Have you ever thoughout of hurting yourself? If so, how long ago?
Who would you reach out to if you were in distress?
Are you experiencing any anxiety, panic attacks or phobias?
Are you experiencing any chronic pain? If so, please describe where and how long you have had this pain.
Please describe your history and current use with cigarettes, drugs, and alcohol.
Are you currently taking any medication?
How would you describe your sleeping habits?
Please share any specific sleep concerns.
Are you currently in a romantic relationship? If so, how long?
On a scale of 1-10, how would you rate your relationship?
Do you have any children? If so, how many?
Please describe each pregnancy and delivery.
Have you ever suffered a miscarriage or had an abortion?
Describe your relationship with your children.
Please describe your relationship with your mother.
Please describe your relationship with your father.
Do you have any siblings? If so, can you describe your relationship?
Have you currently experienced any stressful or life-altering events? If so, please describe.
Have you ever been in therapy? If so, how long?
How did you decide to end your therapy?
What would you like to accomplish in your time in therapy?
Submit
Thank you!
bottom of page