Behavioral Health Intake Form

General Information

Primary Language *
Gender Identity *
Sexual Orientation? *
Gender Pronoun *

Contact Information 

Can Voicemail Messages Be Left For You To Receive? *
Aside Fom Telephone Calls, Please Let Us Know How You Would Like To Receive Information and Notifications From Our Team. *

Personal Information 

What Is Your Current Living Situation? *
Current Relationship Status? *
Do You Have Children? *
Ethnicity *
Race *
Grade of Education Last Completed *
Are You A Current Student? *
Do You Have Current or Prior Military Service? *
Who Did You Grow Up With? *
What Is Your Income Source(s)? *

Health Questionaire

What Is Your Overall Health? *
Have You Ever Been In Counseling/Therapy Services? *
Current Smoker? *
If yes as a current smoker, please answer the following?
In The Last 2 Weeks Have You Used Any Substances? *
0/255 characters
Are You Currently Taking Any Medications? *
0/255 characters
Do You Have Any Preferences For A Counselor? *
0/255 characters
0/255 characters
Level Of Care Services? *

Reason For Referral To Mental Health Services/Therapy.

Please Check All That Apply. *

Over The Past 2 Weeks, How Often Have You Been Bothered By Any Following Problems?

The undersigned client* or responsible adult** consents to and authorizes mental health services by: The AMAAD Institute These services may include psychological testing, psychotherapy/counseling, rehabilitation services, medication, case management, laboratory tests, diagnostic procedures, and other appropriate services. While these services may be delivered at a different location, services provide within the Los Angeles County mental health system will be coordinated by the staff of a single agency. *