STANDARD INTAKE FORM

Randall R. Lyle, Ph.D., LMFT, BCIA-EEG
1120 2nd Ave. SE
Cedar Rapids, IA 52403
319-261-2291 Office, 319-538-0196 Fax

Your information is secured by SSL encryption and password protection

Client:	Gender: Female Male
	O.K. to send email? Yes No




Relational status: Single Married Committed Rel Separated Divorced Widowed
Number of persons other than yourself living in your household? Adults: Children:

Partner/ Spouse/ Parent:

Name of Child (minor and adult)	Gender	Age	Descriptive Comment
	Female Male
	Female Male
	Female Male
	Female Male
Have you experienced any major changes or events in your life during the past year? Yes No
Have you lost a friend, family member or other significant person during the past year? Yes No
Are you presently seeing another counselor? Yes No If yes, who?
Have you had previous counseling or psychotherapy? Yes No Where?
What brings you to therapy?

Physician: Phone #

Are there any health conditions I should be aware of? Yes No

If yes, please describe:

Are you currently taking any medications? Yes No

If yes, please list and give the reason.

How important is spirituality to you in addressing the concerns that brought you to counseling?

Are you active in a church or other spiritual community? Yes No If yes, which?

Dr. Lyle wishes to acknowledge and thank members of the professional community for their trust in referring persons to him for counseling. Your signature below gives him permission to make such contact by phone or letter.

Referring Individual:

Your Signature: By checking this box you are signing this document and your computer's IP address will be logged.

CANCELLATION AND RETURNED CHECK POLICIES

Dr. Lyle charges for sessions canceled with less than 24 hours notice.

There will be a $25 charge for each returned check or “do not honor” credit card payment.

I have read and understand these policies.

By checking this box you are signing this document and your computer's IP address will be logged.