INTAKE FORMMLL LICENSED CLINICAL SOCIAL WORK SERVICES, PLLCMARILYN L. LAVES, LCSW-R Name * First Name Last Name Birth Date * MM DD YYYY Gender * Male Female Other Prefer not to say Age * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### May I leave you a message? * Yes No Email * *Please note: Email correspondence is not considered to be a confidential medium of communication. May I email you? * Yes No Emergency Contact * First Name Last Name Emergency Contact Phone * (###) ### #### Referred by (if any) Health Insurance Information Company ID# Group # Co-pay Amount Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc.)? * Yes No Are you currently taking any prescription medication? * Yes No Please list Have you ever been prescribed psychiatric medication? * Yes No Please list and provide dates Thank you!
