01

Who You Are

Basic personal details

Your name

First name *

Last name *

Preferred name

Pronouns

About you

Date of birth *

Gender identity

Ethnicity / background

Occupation

Employer / school

Contact

Cell phone *

Email *

Home address

How did you hear about Trinsic?

Friend / family

Healthcare provider

Psychology Today

Online search

Social media

Other

02

Your Anchor

Emergency contact information

Their name *

Relationship to you

Their phone *

Their email

May we contact them on your behalf in a mental health emergency?

Yes

No

Let's discuss

03

Coverage

Insurance & billing details

Insurance company

Plan name / type

Member ID

Group number

Insurance phone

Policy holder (if different from you)

Policy holder name

Policy holder DOB

Relationship to you

04

What Brings You Here

Your concerns and intentions for this work

05

The Road So Far

Mental health history & prior treatment

Previous therapy

Have you been in therapy before?

Yes

No

When (approx)?

Type of therapy or approach?

What was helpful? What wasn't?

Diagnoses & hospitalizations

Any prior psychiatric or psychological diagnoses? A label doesn't define you. This just helps us understand your history.

Any psychiatric hospitalizations?

Yes

No

When and what was the context?

Current providers

Current psychiatrist or prescriber

Currently seeing another therapist?

Yes

No

06

Body & Mind

Medical history and current medications

Current medications

List any medications you're currently taking

Physical health

Any current or past medical conditions?

Allergies (medications or other)

Primary care provider

07

Substance Use

Non-judgmental check-in on use patterns

This section is here to help your therapist understand the full picture, not to judge. Answer with what feels honest.

Current use

Alcohol

Cannabis

Tobacco / nicotine

Other substances

Context

Any personal concerns about your use, or past history with substance use?

08

Your World

Relationships, living situation, family history

Home & relationships

Relationship status

Living situation

Children?

Support network

Family background

Any history of mental health concerns in your family?

How would you describe your childhood, generally?

Stable and nurturing

Mixed, good and hard

Difficult or traumatic

Complex, hard to summarize

09

A Safety Check-In

Standard questions we ask everyone

These questions are standard for all new clients. They help your therapist know how to best support you. Your honesty is safe here.

Current thoughts

Are you currently having any thoughts of harming yourself?

No

Passive thoughts (e.g. "I wish I wasn't here")

Active thoughts

Can you tell us a little more?

Are you currently having any thoughts of harming someone else?

No

Yes

Please share more

History

Any past history of self-harm?

No

Yes

Any past suicide attempts?

No

Yes

10

Anything Else

Space for whatever didn't fit above

For your therapist

Is there anything you want your therapist to know before your first session?

Cultural, spiritual, or religious considerations

Accessibility needs

11

Your Agreement

Consent to treatment and confidentiality

Acknowledgments

I understand that the information I share in therapy is confidential, with limits required by law (including imminent risk of harm to self or others, and mandatory reporting).

I consent to beginning therapy services with Trinsic and understand that I may discontinue at any time.

I understand that therapy is a collaborative process and that progress depends in part on my own engagement and willingness to engage honestly.

I confirm that the information I've provided in this form is accurate to the best of my knowledge.

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