Dr Tekesia Jackson Intake Form
Forms should be completed 3 days or more prior to your appointment to ensure that the clinician is able to review your intake prior to your session.

Office information:
-7th floor
-Inform receptionist you are there to see Dr Jackson
- Parking is in the front of the building, including the back and the parking structure for free.
-Please do not park in the parking lot of 24 hour fitness.
Patients name*
If family, enter other members & Relationship
Patients date of birth*
Patient or guardians Phone number*
Patients Full Mailing Address *
Email address *
Payment for Services*
Anthem MediCal Only
Beacon LA Care
Beacon Health Options
Cigna
Cigna EAP
Kaiser
MHN
MHN MediCal
MHN EAP
Private Pay
PPO- Request Superbill
Insurance- Member ID number
Insurance-Subscriber Name and DOB if not patient
Subscriber address if different from patient
What brings you to counseling at this time? *
What are your goals for counseling?*
Have you seen a mental health professional before*
Yes
No
If yes, provide dates and reason
List medications, supplements, reason & dosage
If prescription, name & number of doctor?
Who is your primary care physician? Number?*
Do you drink alcohol?*
Yes
No
If yes, frequency and amount?
Do you use recreational drugs?*
Yes
No
If yes, type, frequency and amount?
Do you have suicidal thoughts?*
Yes
No
If yes, when was the last time? Reason?
Have you ever attempted suicide?*
Yes
No
If yes, list dates and reason?
History of psychiatric hospitalizations?*
Yes
No
If yes, list dates, location & reason
Is there mental health history in your family?*
Yes
No
If yes, please describe relationship & diagnosis
Are you in a relationship? Please describe*
What is your highest level of education?*
What is your current occupation?*
Please describe any history of trauma
Check symptoms experienced in the last 6 mths
Change in appetite
Check the box if true
Change in sleep pattern
Check the box if true
Trouble concentrating
Check the box if true
Isolation from others
Check the box if true
Depressed or sad mood
Check the box if true
Tearful or crying spells
Check the box if true
Anger outbursts
Check the box if true
Anxiety
Check the box if true
Head injury or seizures
Check the box if true
Low motivation
Check the box if true
Receive email updates from office? *
Yes
No