Mindfulness-Based Therapy Initial Intake Form
Personal Information
Full Name
Date of Birth
Email Address
Phone Number
Address
Emergency Contact
Emergency Contact Name
Relationship
Emergency Contact Phone
Referral
How did you hear about us?
Present Concerns
Please describe your main reasons for seeking therapy
What goals or outcomes would you like to achieve through therapy?
Mental Health History
Have you previously attended therapy or counseling?
Yes
No
If yes, please give details
Any previous mental health diagnoses?
Are you currently taking any medications?
Physical Health
Any significant medical conditions?
Primary Care Physician
Mindfulness Experience
Have you practiced mindfulness or meditation before?
Yes
No
If yes, please describe your experience
Additional Information
Any questions or anything else you'd like to share?