SDT Intake Form Name First Last Home Address Street Address Address Line 2 City ZIP / Postal Code PhoneEmail Emergency Contact Name First Last Emergency Contact PhoneDate of Birth MM slash DD slash YYYY AgePlease enter a number greater than or equal to 0.Ethnicity Sexual Orientation Level of Education Marital Status Length of Time in Relationship Number of Children / Age of ChildrenOccupation Years at JobAlcohol Use/Abuse HistoryDrug Use/Abuse HistoryBirthorder Illness/SurgeriesLegal IssuesHistory of Mental IllnessHistory of Family Mental IllnessPrior Psychotherapy Experience Presenting Issue
