Lisa Strauch Scott, Psy.D.
​Licensed Clinical Psychologist
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New Patient Intake Form
Thank you for choosing to meet with me. Please complete this form with as much information as you feel comfortable providing at this time. The information you provide will help me to prepare for our first meeting. Please do not hesitate to contact me if you have any questions or concerns.





























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Protestant
Catholic
Jewish
Muslim
Buddhist
Hindu
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I have no problems or concerns at this time
Abuse - physical, sexual or emotional
Academic concerns
Aggression/violence
Alcohol use
Anger, hostility, arguing, irritability
Anxiety/nervousness
Attention, concentration, distractibility
Career concerns
Childhood issues (your own childhood)
Codependence
Confusion
Custody concerns
Decision making, indecision, mixed feelings, putting off decisions
Delusions (false ideas)
Dependence
Depression (low mood, sadness, crying)
Divorce/separation
Drug use (prescription medicines, over-the-counter medicines, street drugs)
Eating problems - overeating, undereating, appetite, vomiting
Emptiness
Fatigue, tiredness, low energy
Fears/phobias
Fertility concerns
Financial or money troubles, debt, impulsive spending, low income
Gambling
Grieving/loss
Guilt
Inferiority feelings
Interpersonal conflicts
Impulsiveness, loss of control, outbursts
Irresponsibility
Judgement problems, risk taking
Loneliness
Marital conflict, distance/coldness, infidelity/affairs, remarriage, disappointments, different expectations
Medical concerns
Memory problems
Menopause
Menstrual problems/PMS
Mood swings
Motivation/laziness
Obsessions/compulsions (thoughts or actions that repeat themselves)
Oversensitivity to rejections
Pain
Panic or anxiety attacks
Parenting
Perfectionism
Poor self-care
Postpartum concerns
Pregnancy concerns
Procrastination
Relationship problems (with friends, relatives, colleagues)
Self-esteem
Sexual issues
Sexual assault/rape
Sexual orientation/identity
Shyness
Sleep problems
Smoking or tobacco use
Spiritual, religious, moral, ethical issues
Stress
Suspiciousness, distrust
Temper problems
Thought disorganization and confusion
Weight and diet issues
Withdrawal/isolation
Work problems
Other







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Disclaimer: 
The information on this website is for informational purposes only. It is not intended to provide psychological advice and is not a substitute for consultation with a licensed mental health professional.
Copyright © 2023
  • Welcome
  • About Me
  • Services
  • Common Questions
  • Payment & Insurance
  • Contact Me