Intake Information

Please complete this form and click "submit" at the bottom.

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Name *

1) What are the names of your parents? *

2) If applicable, what are the names/ages of your siblings? *

3) Have you, or any of your family members, ever dealt with/are dealing with addiction (substance or behavioral)? Please explain: *

4) Do you practice a faith-based religion or spiritual pursuit? Please explain: *

5) Do you have any specific medical conditions or concerns? Please explain: *

6) Are you currently taking any medications? If so, please indicate the name and dose of each medication: *

7) Please list and briefly explain any traumatic or significant events you have experienced: *

8) What are your observations of how you relate to others in general? Any patterns? Any habits? Any feedback you commonly hear from others? Please describe: *

9) Finally, what are the overall goals you would like to achieve in therapy? What would you like to accomplish or see change through the process of therapy? *

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Intake Information

Dr. Shannon Francom, LMFTand Associates

Dr. Shannon Francom, LMFT
and Associates