INTAKE FORM

Full Name*
Address*

Contact & Personal Information

MM slash DD slash YYYY
Are you currently in a romantic relationship?
As it appears in the insurance card
How did you find Transcendent Truth, Inc?
Full Name (Age)
Do you attend church?
Name of Church and Phone Number

General Health And Mental Health Information

How would you rate your current sleeping habits?*
How would you rate your current physical health?*
Are you currently experiencing overwhelming sadness, grief, or depression?*
Are you currently experiencing anxiety, panic attacks, or have any phobias?*

Substance Abuse

Do you drink alcohol more than once a week?
Is alcohol an area of concern for you?
How often do you engage in recreational drug use?
Is recreational drug use an area of concern for you?

Family Mental Health History

In the section below, identify if there is a family history of any of the following. If yes, please indicate the family member’s relationship to you in the space provided (father, grandmother, uncle ECT.).

Alcohol/Substance Abuse
Anxiety
Depression
Domestic Violence
Eating Disorders
Obesity
Obsessive Compulsive Behavior
Schizophrenia
Suicide Attempts
Suicide Attempts

Abuse History

Have you experienced physical, sexual or emotional abuse?

Additional Information

Insurance Information

Information about Parent or Responsible Party for Insurance

Full Name of Primary Insured*
MM slash DD slash YYYY
Max. file size: 50 MB.
Please upload pictures of your insurance card FRONT and BACK

Confidentiality Agreement

Tele Mental Health Informed Consent - Please click here to review this document

Transcendent Truth Intake Assessment - Click here to review this document

Informed Consent For Assessment and Treatment - Click here to review this document

Notice of Privacy Practices - Click here to review this document

Consent*
Consent*
Patient's Full Name*
MM slash DD slash YYYY