Contact Aida & Intake Form

All boxes with a red asterisk * must be filled in for the form to be submitted.

Thank you.

Last Name: *

Medication taken for psychological or medical reasons (e.g., Librium, Valium,etc.) give current medication, dosage, and illness

Have you ever been hospitalized?: *

Email:

Check here to receive email updates

If yes, for what conditions?: *

Have you been in therapy before?: *

Emergency contact:

Can Aida thank whomever referred you?:

Evening Phone:

Are you having any thoughts of committing violence towards others or property?: *

If necessary, can a message be left on your home phone?: *

Home phone: *

Problem?: *

How long employed?: *

Employer: *

Address Street 1: *

Present health quality (excellent, good, poor) *

SAFEHAVEN PSYCHOTHERAPY

Current Medical Doctor: *

Zip Code: *

Occupation: *

Age: *

First Name: *

Aida Baker
Licensed Marriage Family Therapist, #51176

Please list any recreational drugs or amount of alcohol currently being used. : *

Length of time in current relationship

Address: *

Name of children and their ages *

Name: *

With whom?:

Name of spouse or live-in partner and their age

Nevada City, CA

530-263-6882
aidabaker.mft@gmail.com

Would you like to be placed on Aida's email list to receive information on events she will be holding?

YES

City: *

Are you having any suicidal thougths or plans at this time?: *

Recurring health problems (explain briefly) *

Address Street 2:

What do you hope to get out of therapy?:

Was it helpful?:

Presenting problem (give a brief history of the problem including when it first occurred and prior attempts at a solution) *

Contact Aida

If yes, when?: *

Have you had suicidal thoughts in the past?: *

Referred by:

Daytime Phone: *

State: *

Birthdate: *

Work phone: *

FINANCIAL OBLIGATIONS
I understand that payment is due at each session unless specific arrangements are made and noted below. I understand that missed or cancelled appointments will incur a charge unless 24 hour notice is given.

CLIENT INFORMATION
New clients please complete this confidential intake form and submit it to Aida.

If a certain question does not apply, please indicate by marking "N/A." Thank you.