Initial Intake Form
Paul J. Hannig, Ph.D. MFT
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
City State Zip
Home Phone Work Phone Cell Phone:
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:
The Benefits of Telephone and Online 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.
Paul J. Hannig, Ph.D MFT w PsychotherapyHELP
Chatsworth, CA 91311 w 818.882.7404 w firstname.lastname@example.org