Dr. Destun & Associates

Psychologists in Private Practice

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Psychologists in Private Practice

September 2017 Not Currently Accepting Couples ; 10-Week Waiting List for Individual Therapy

Adult Therapy Intake Form

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Contact Information

Your Information:

(check if voicemail is OK)

Emergency Contact:



Physician Information

Family Doctor:



Psychiatrist (if applicable):


How did you find us?






Education and Employment

Employment:





Highest grade completed:

Family of Origin



Health History and Treatment










Current Habits

Please describe your current habits in each of the following areas. Please indicate frequencies/amounts and types where appropriate.








Current Problems and Therapy Goals




(none)

(extreme)



































(not)

(extremely)


(not)

(extremely)


Strengths and Supports

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