Intake form: You may fill this form out online**, click here, print and bring it with you, or fill it out in our office when you arrive. 

Name *
Date of Birth
Date of Birth
Ok to contact you?
Ok to send a text message appointment reminder?
I hereby authorize the release of any information acquired in the course of my treatment to my insurance company. I hearby authorize payment directly to Cullman Family Counseling for my insurance benefits, if any, otherwise payable to me for services rendered. I permit a copy of this authorization to be used in place of the original. I understand that if reimbursement isn’t received from my insurance company within 60 days, I am responsible for payment of services rendered. Signature: _______________________________________ Date: __________________
Thoughts of suicide
Problems Concentrating
Crying spells
Feeling Depressed
Problems Sleeping
Relationship Problems
Problems with Alcohol
Job Problems
Thoughts of hurting others
Weight gain or loss
Feeling Hopeless
Feeling anxious or nervous
Less or more hungry than usual
Legal problems
Problems with drugs
Problems with the past
Have you received therapy in the past for this, or other problems?
Are you currently receiving therapy from another mental health professional?
If yes, with whom and for what problem?
For how long? Number prior marriages
Are you willing for your PCP to be contacted regarding your treatment?
Have you ever decided to cut down on your use of alcohol and drugs?
Have you ever been annoyed by questions about your use of alcohol and drugs?
Have you ever felt guilty about your use of alcohol/ drugs?
Have you ever needed a morning eye-opener?
Do you believe that you have a problem with your use of alcohol/drugs?
Has anyone ever expressed concern about your use of alcohol/ drugs?
Have you ever been the victim of physical abuse?
Have you ever been the victim of sexual abuse?
Other trauma?
Are you involved in organized religion?
Do you consider your spiritual life to be important to you?

** Please note that by submitting the form online, your responses will be sent to our email address, which may not be housed on a HIPAA approved server. 

Download Intake Form

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