California Center for Behavioral Health

925 Ygnacio Valley Road, Ste 205, Walnut Creek, CA 94596 · (925) 289-9022 · Fax (888) 965-0556

Intake Questionnaire

Please complete this questionnaire so Dr. Sekhon's team can prepare for your first visit.

Please note: Submitting this form does not initiate care or establish a doctor-patient relationship. Our team will review your submission and reach out to schedule. For emergencies call 911 or 988.

Patient Information

Full Name

Date of Birth

SSN (optional — last 4 acceptable)

Address

City

Zip Code

Cell Phone

Home Phone

Insurance

Insurance Carrier

Insurance Phone

Insurance ID

Group #

Primary Insured Name

Primary Insured DOB

Primary Insured Address

City

State

Zip

Emergency Contact

Name

Relationship

Cell Phone

Home Phone

Other Providers

Primary Care Doctor

PCP Phone

Therapist / Psychologist

Therapist Phone

Symptoms / Reason for Visit

Describe your main concerns or reason for seeking care

Previous Psychiatric Medications

Medication	Dates	Dose	Effect

Therapy History

Are you in therapy now or have you been in therapy before? If yes, please describe.

Psychiatric Hospitalizations

Any psychiatric hospitalizations? If yes, list reason, dates and hospital.

Medical History

Current Medical Problems / Diagnoses

Pregnant?

Yes No N/A

Planning pregnancy in next year?

Yes No N/A

Breastfeeding?

Yes No N/A

Using contraception?

Yes No N/A

Method of contraception

Current Medications

Medication Name	Dose	Diagnosis	Duration

Medication Allergies

List allergies and reactions (enter "None" if no allergies)

Habits — Current or in the Past

	How Much	How Often	When	Problems Caused by Use
Alcohol
Tobacco
Drugs (list names)
Marijuana
Caffeine

Family Psychiatric History

Anyone in your family with a history of depression, anxiety, bipolar disorder, schizophrenia, etc.?

Personal History

Where were you raised?

Raised by

Highest Education Level

Ages of Siblings

Marital Status

Name of Significant Other

Ages of Children

Occupation

Years at Job

Any problems at work/school?

Have you been arrested?

Submit Your Intake

By submitting, you confirm the information above is accurate to the best of your knowledge.

Signature (type full legal name)

Date