Jessica L. Harvey, MFT
735 Montgomery St, Suite 300
San Francisco, CA 94111
Marriage & Family Therapist
MFC#49458
3253 Steiner St
San Francisco, CA 94123
www.jessicaharveytherapy.com
CONFIDENTIAL CLIENT INTAKE FORM
Client Name________________________________________________Date______________________
Date of Birth_________________________ Age_______
Street Address___________________________________City_________________________________
State ____________Zip Code ____________E-mail Address___________________________________
Cell Phone ___________________ Home Phone____________________ Work Phone _______________
Which of these numbers do you prefer to be contacted on, keeping in mind that I may need to leave a message:
___________________________
Employer______________________________Occupation____________________________________
Relationship Status___________________________Children__________________________________
In Case of Emergency
Notify_________________________________Relationship___________________________________
Phone Number___________________________
Referral:
How did you hear about Jessica Harvey? (check one please)
___ Friend or Family If so, Who? _______________________________________________
___ Physician/Psychiatrist If so, Who? ___________________________________________
___ Television/Magazine/Newspaper
___ Internet If so, what site? _________________________________________________
___ Other __________________________
Presenting Problems:
Please describe your reasons for seeking therapy:
___________________________________________________________________________________
___________________________________________________________________________________
Please circle the severity of your problem(s) on the scale below:
mildly upsetting moderately upsetting very severe extremely severe completely incapacitating
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Circle all that apply to you:
depressed mood/sadness
difficulty concentrating
sleeping difficulties
feeling lonely
anxiety /stress
headaches
stomach trouble
feel “on edge”/tense
alcohol use
confusion
relationship difficulties
difficulty making friends
low energy
irritability
appetite changes
excessive guilt
panic attacks
dizziness
pain (please describe)
nightmares
drug use
obsessive thoughts
financial problems
low self-esteem
tearfulness
behavioral concerns
low motivation
fatigue
change in weight
feel worthless
suicidal thoughts
feel like a failure
anger problems
fears /phobias
fainting spells
palpitations
unable to relax
restless/nervous
flashbacks
memory problems
sexual problems
legal problems
difficulty trusting
difficulty making decisions
shy with people
academic/work problems
other not listed:___________________________
Family History:
Describe any significant emotional, medical or chemical dependency conditions of your parents/family:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Alcohol/Substance:
Please describe alcohol/substance (drugs, etc) use:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Previous Experience with Therapy:
Please list any periods in the past that you received therapy, what you were treated for, and what you found
beneficial/not beneficial about the experience:
______________________________________________________________________________________________
______________________________________________________________________________________________
___________________________________________________________________________________________
Additional Information:
Additional problems or difficulties you think may be important for the therapist to know:
______________________________________________________________________________________________
__________________________________________________________________________
Consent for Treatment: I authorize and request that Jessica L. Harvey, M.A., provide assessment, treatments,
and/or diagnostic procedures which now or during the course of my care as a client are advisable. I understand
that the purpose of these procedures will be explained to me upon my request and subject to my agreement. I
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understand that the therapist is a Marriage and Family Therapist MFC#49458. I also understand that while the
course of therapy is designed to be helpful, it may at times be difficult and uncomfortable
Your signature below indicates that you have read and understood the information of the Out Patient Service
Contract and agree to abide by the terms of the Out Patient Services Contract.
Your signature below indicates that all the information on this form is accurate.
_______________________________________ ___________________________________ ____________
Client (print)
Client (sign)
Date
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