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.
If family, enter other members & Relationship
Patients Full Mailing Address *
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*
If yes, provide dates and reason
List medications, supplements, reason & dosage
If prescription, name & number of doctor?
Who is your primary care physician? Number?*
If yes, frequency and amount?
Do you use recreational drugs?*
If yes, type, frequency and amount?
Do you have suicidal thoughts?*
If yes, when was the last time? Reason?
Have you ever attempted suicide?*
If yes, list dates and reason?
History of psychiatric hospitalizations?*
If yes, list dates, location & reason
Is there mental health history in your family?*
If yes, please describe relationship & diagnosis
Are you in a relationship? Please describe*
What is your current occupation?*
Please describe any history of trauma
Receive email updates from office? *