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804-270-1124 Richmond, Virginia

Outpatient Mental Health Treatment, Counseling & Therapy

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Careers
Location

Adult Intake Form

Adult Intake Form

Patient Demographics

Last Name *

First Name *

Middle Initial

Preferred Name

Select One:

Male

Female

Non-Binary

Other

Birthdate

Age

Marital Status

Single

Married

Divorced

Widowed

Separated

Partnered

Home Phone #

Cell Phone #

Home Address *

City *

State *

Zip *

Occupation

Employer

Work Phone # *

Ext.

Would you like to receive appointment reminders?

Yes

No

Please select which phone number you would like to be contacted for appointment reminders:

Home

Work

Cell

If you wish to receive appointment reminders by email, please provide your email below:

I give permission for relevant confidential information to be left on my home answering machine and/or cell voice mail? *

Yes

No

Who referred you to our practice?

Were you referred to a specific provider at DBH? *

Yes

No

If yes, which one?

Mental Health History

Have you received counseling, psychological, or psychiatric services in the past? *

Yes

No

If yes please provide the Professional’s Name and dates of treatment below:

Name of Professional

Service Began

Services Ended

Name of Professional

Service Began

Services Ended

Have you ever been hospitalized for mental health reasons? *

Yes

No

If yes, when?

Where?

Length of Stay

Reason for Hospitalization

Medical History

Primary Care Physician

Office Address

City

State

Zip

Office Phone #

Fax #

Please list ALL current medications:

Medication

Dosage

Prescribing Doctor

Medication

Dosage

Prescribing Doctor

Medication

Dosage

Prescribing Doctor

Emergency Contact

Their Name

Relation

Home Phone #

Cell Phone #

Responsible Party (if different from patient)

Name

DOB

Relation to Patient

SSN

Billing Address

City

State

Zip

Contact #

Email

Employee Assistance Program (EAP)

Are these visits covered by Employee Assistance Program (EAP) benefits?

Yes

No

If yes, please provide the following information:

Name of EAP company

Authorization #

Allotted Number of Visits

EAP Start Date

EAP End Date

Primary Insurance

Insurance Company *

Policy ID# *

Policy Holder *

Select One: *

Male

Female

OtherOther

DOB *

Relation *

Address *

City *

State *

Zip *

Insurance Contact # *

Secondary Insurance

Insurance Company

Policy ID#

Policy Holder

Select One:

Male

Female

DOB

Relation

Address

City

State

Zip

Insurance Contact #

Please Select One:

Insurance information provided *

I hereby authorize DBH to release necessary medical information to my insurance company. I further authorize direct payment to the above entities from the above listed company. I understand that I am responsible for obtaining referrals, if necessary, and paying and co-payment, co-insurance, or deductibles required by my Plan. I also understand that I may be responsible for the full amount in the event of non-coverage determined by my plan. If my account is not paid when due, I further agree to pay any collection expenses upon my account being turned over to the Collections. I further understand that it is my responsibility to notify DBH when/if my insurance changes.

No insurance information provided

I agree to pay in full by check, credit or money order at or before the date of service. If my account is not paid when due, I further agree to pay any collection expenses upon my account being turned over to the Credit Adjustment Board.

I understand that the following charges are not covered by insurance: $20-Medication Refill Fee, $75-No Show/Late Cancellation Fee (we require 24 hours notice for a cancellation) $125-Bariatric Form Writing Fee. $120 (per hour)-Completion of Paperwork/ Letter Writing Fee. For other fees not covered by insurance please refer to the financial agreement. l I further understand that I may request a full copy of DBH’s financial agreement at any time.

Patient Signature *

Date *

Have you had any of the following problems in the last month?

Anxiety/Excessive Worrying

Yes

No

Panic Attacks

Yes

No

Extreme Fear

Yes

No

Sadness

Yes

No

Depressive Mood

Yes

No

Suicidal Thoughts

Yes

No

Sleep Problems

Yes

No

Lack of Energy/Motivation

Yes

No

Anger Problems/Irritable Mood

Yes

No

Excessive Energy

Yes

No

Trauma

Yes

No

Undue Stress

Yes

No

If yes, please explain

Lack of Self-Control

Yes

No

If yes, please explain

Concentration Problems

Yes

No

Memory Problems

Yes

No

Work/Career Problems

Yes

No

Educational Problems

Yes

No

Alcohol Use/Abuse

Yes

No

Other Substance Use/Abuse

Yes

No

Legal Problems

Yes

No

Problems with Children

Yes

No

Marital/Relationship Problems

Yes

No

Domestic Violence

Yes

No

Separation/Divorce

Yes

No

Grief/Loss

Yes

No

Financial Problems

Yes

No

Health Problems/Major Illness

Yes

No

Gender Concerns

Yes

No

Eating Problem/Eating Disorders

Yes

No

Other

Please explain briefly your reason/reasons for seeking help at this time

Please provide any additional information that you believe may be helpful

Lifestyle Questions

Nutrition

Do you eat a healthy, well balanced diet most of the time?

Yes

No

Would you like to improve your diet?

Yes

No

Are you currently dieting?

Yes

No

Exercise

I exercise regularly

Yes

No

If yes, approximately how many days per week do you exercise?

Sleep

Insomnia?

Yes

No

Sleep too much?

Yes

No

Average hours nightly

Do you take medication to help you sleep?

Yes

No

Smoking

Do you smoke, chew or vape tobacco?

Yes

No

Average used daily

If yes, are you interested in stopping?

Yes

No

Social Network

Do you engage in positive daily social interactions?

Yes

No

Do you have anyone you feel comfortable confiding in?

Yes

No

Hobbies

Do you have any hobbies you enjoy participating in on a regular basis?

Yes

No

Stress Management

Do you feel under stress?

Yes

No

If yes, answer the following questions

Do you have specific ways of reducing stress?

Yes

No

Examples

Would you like to learn new/additional ways of reducing stress?

Yes

No

Alcohol

Do you drink alcohol?

Yes

No

Beer?

Y

N

Wine?

Y

N

Liquor?

Y

N

Least per day?

Most per day?

Do you typically drink more on weekends?

Yes

No

Non Prescription Drugs

Non Prescription Drug Use?

Yes

No

Type of drug(s)

If you are human, leave this field blank.

Δ

Looking for a helping hand?

Let the professionals at DBH guide you on your path of recovery.

Richmond Office

Dominion Behavioral Healthcare
Main Office & TMS Center
2301 North Parham Rd, Suite 5
Richmond VA 23229

Phone: 804.270.1124
Fax: 804.270.2090

Copyright 2025 | Dominion Behavioral Healthcare | Richmond, Virginia | Privacy Policy | Website by Jonas Marketing

If you are interested in becoming a new patient at DBH, please complete and submit the new patient registration form (18 yrs +) or the child new patient registration form (>18 yrs) linked below.

Welcome! We’re glad you’re here.

Once the completed form is submitted, our new patient coordinator will contact you to review your submission and discuss how DBH may best serve you.

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