Paul J. Hannig, Ph.D.

Initial Intake Form 
 

PsychotherapyHELP

 


Search
Go


 WELCOME ...



PsychotherapyHELP Home


Dr. Paul Hannig


 THERAPY



Hypnosis: Beyond Therapy


Teletherapy: Telephone & Skype Video Sessions


E-Therapy


Deep Feeling Therapy


Music in Therapy


Separation Counseling


The Love Program


Healing Meditations


Power of Prayer/Psycho-Spiritual Therapy


 BEST SELLERS



ONLINE STORE: Manuals, Books & E-Books


ONLINE STORE: Media Programs


Mail Order Form


 



 FREE RESOURCES



Mood, Anxiety, & Personality Disorders


Feeling Therapy Articles


FREE Articles


FREE Manual Excerpts


Newsletters


Online Tests


Web Links


 GROWTH & CHANGE



Addictions


Soulmates from Hell


Soul Mating


Managing Your Anger - NEW!


Depression


Secrets of Success


Dealing with Time Bandits


Reinvent Yourself!


Catching Yourself


Married People - Unmarried Minds


The Power to Convince


 FOR YOU ...



Daily Thoughts


People Are Saying...


 MAILING LIST



Subscribe to our Mailing List!


 THERAPY FORMS



Initial Intake Form


Therapy Guidelines & Confidentiality


 CONTACT US



Contact Us!

Paul J. Hannig, Ph.D. MFT  
PsychotherapyHELP  
818-882-7404  

phannigphd@att.net  


Sitemap






Instructions:  Your personal information and signed consent to begin therapy is required and it is important to have this information on file. Please print this form, fill out the necessary information, sign, and mail to Dr. Hannig prior to beginning any therapy.

 

 

Initial Therapy Intake Form

 

 

Name                                                                                          Age                  Birthdate                           

Address                                                                                      Email                                                             

City                                                                                              State                          Zip                             

Home Phone                                 Work Phone                                          Cell Phone:                                      

Occupation                                                                      Employer                                                                   

Marital Status                                          Name of Spouse/Partner                                                                      

How Long Have Both of You Been Together?                                  Religion                                                          

If Client is a Minor, Name of Responsible Adult                                                                                                    

Name of Closest Friend/Relative                                                                Phone                                                

Address                                                                          City                                     State           Zip               

There are times when prior medical and psychological records will be requested.

Please make sure that all information given below is correct.

 

Do You Smoke?                        How Much?                         Do You Drink?                        How Much?               

Do You Take Drugs?                  If yes, what kind?                                               How often?                               

Last Medical Examination                                   Reason                                                                                    

Are You Now Under a Doctor's Care?                   If yes, Doctorís name:                                                               

Reason for Doctorís Care:                                                                                                                                  

Are You Taking Any Medication?             If yes, what kind?                                                                                       

Reason for Medication:                                                                                                                                   

Have You Ever Been Hospitalized for a Physical Illness?   Describe:                                                                     

                                                                                                                                                                       

Have you ever been Hospitalized for a Mental Illness, Personality Disorder, Anxiety Disorder, etc? Describe:                                                                                                                                                                        

Any Previous Therapy/Counseling?                  If Yes, Name and Phone Numbers of Therapists:                                                                                                                                                           

When and Number of Sessions:                                                                                                                         

Type of Therapy/Counseling:                                                                                                                              

How referred to Dr. Hannig:                                                                                                                                

What do you Wish to Achieve with Therapy?                                                                                                           

                                                                                                                                                                        

                                                                                                                                                                         

Check Any of the Following That May Apply to You:

 

Headache

 

Inferiority Feelings

 

Shy With People

 

Dizziness

 

Feel Tense

 

Canít Make Friends

 

Fainting Spells

 

Feel Panicky

 

Afraid Of People

 

No Appetite

 

Fears and Phobias

 

Home Conditions Bad

 

Over-Eating

 

Obsessions

 

Unable To Have A Good Time

 

Stomach Trouble

 

Depressed

 

Always Worried About Something

 

Bowel Disturbances

 

Suicidal Ideas

 

Donít Like Weekends/Vacations

 

Always Tired

 

Take Tranquilizers

 

Canít Make Decisions

 

Always Sleepy

 

Alcoholism

 

Over-Ambitious

 

Unable To Relax

 

Dangerous Drugs

 

Financial Problems

 

Insomnia

 

Allergy

 

Gambling

 

Recurrent Dreams

 

Asthma

 

Job Problems

 

Nightmares

 

Homosexuality

 

Canít Keep A Job

 

Hallucinations

 

Sexual Problems

 

Other

 

 

                                                                                 

The Benefits of Telephone and Online Therapy

Telephone Therapy:

Telephone and online therapy has no time or location boundaries!  Sessions can be done at any time of day or night in the complete privacy and comfort of your home or office. Turn around response time for online therapy is excellent and allows for more measured and thoughtful responses. Busy schedules? Traffic? Car in the repair shop? Illness? No problem -- therapy adapts to your schedule needs by offering complete flexibility of location and time.

Clients have reported dramatic results: increased independence, improvement in decision-making and interpersonal relationships, more taking of responsibility for self-help and interpersonal engagement, plus improved relational skills within groups and individuals.

Telephone and online therapy is a perfect medium for teaching very valuable therapeutic skills covering marriage counseling, mental health matters, crisis intervention, spiritual counseling, assessment and coaching concerned relatives of individuals afflicted by various disorders.

To ensure privacy, adequate safeguards can be utilized for confidentiality including the employment of tools and secure chat rooms, digital signatures, encrypted e-mails, secret passwords and other advanced technical safeguards.

Telephone and online guidelines are set by professional organizations. The California Board of Behavioral Sciences sets stringent guidelines for licensed professionals and provides information to consumers at http://www.bbs.ca.gov/psyonlin.htm.

Telephone and online therapy provides access for the homebound, geographically isolated or stigmatized client who will not or cannot access local treatment. Hearing disabled people, celebrities, business travelers, shy and introverted people, concern about stigma and the socially phobic are but some of the individuals who benefit from this type of therapy. Self-help materials are also highly available with online services.

Many misunderstandings and misinterpretations that occur in face-to-face therapy may be minimized with telephone and online treatment.

 

Online (Email) Therapy:

Many people find it easier to express their feelings and thoughts by writing and typing out their internal experiences on a computer. For example: one young man was able to adequately express his anger through online typing in a way that was more effective than any other avenues of expression that were available to him.

Email therapy offers more ease of comfort and safety for those individuals who have difficulty opening up and talking about themselves in front of another person. Some individuals are more honest, more uninhibited, and more expressive in writing than face-to-face or on the telephone. As such, email therapy offers a level of personal privacy that extends beyond what telephone therapy and face-to-face treatment can offer.

With online therapy, you can set your own pace. You can take time to compose, reflect on your responses and those of your therapist, and respond when you are ready. Messages are usually answered within 24 hours of receiving an email. It is an excellent way to review session topics, insights and assignments. It is a first-rate source of note and record keeping for both the client and the therapist.

 

Please Complete Your Insurance Information (CA Clients Only):

Insurance Company                                                         Policy Number                                                            

Address                                                                          City                                 State             Zip                      

Phone                                                     Group Number                                                                                         

May we say who we are if we phone your home?                                                                                                      

May we say who we are if we phone your work?                                                                                                                         

 

 

Upon my signature below, I hereby attest that all the information furnished is true and correct.

 

 

 

 

                                                                                                                       

Signed                                                                                                  Date                                            

                                                                      






PsychotherapyHELP Home  |  Dr. Paul Hannig  |  Hypnosis: Beyond Therapy  |  Teletherapy: Telephone & Skype Video Sessions  |  E-Therapy  |  Deep Feeling Therapy  |  Music in Therapy  |  Separation Counseling  |  The Love Program  |  Healing Meditations  |  Power of Prayer/Psycho-Spiritual Therapy  |  ONLINE STORE: Manuals, Books & E-Books  |  ONLINE STORE: Media Programs  |  Mail Order Form  |  Mood, Anxiety, & Personality Disorders  |  Feeling Therapy Articles  |  FREE Articles  |  FREE Manual Excerpts  |  Newsletters  |  Online Tests  |  Web Links  |  Addictions  |  Soulmates from Hell  |  Soul Mating  |  Managing Your Anger - NEW!  |  Depression  |  Secrets of Success  |  Dealing with Time Bandits  |  Reinvent Yourself!  |  Catching Yourself  |  Married People - Unmarried Minds  |  The Power to Convince  |  Daily Thoughts  |  People Are Saying...  |  Subscribe to our Mailing List!  |  Initial Intake Form  |  Therapy Guidelines & Confidentiality  |  Contact Us!

Paul J. Hannig, Ph.D MFT w PsychotherapyHELP

Chatsworth, CA 91311 w 818.882.7404 w phannigphd@att.net


Sign In