Dr. Destun & Associates

Psychologists in Private Practice


January 2020 Accepting Referrals January 2020

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


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







Strengths and Supports

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