Hygge Behavioral Health & Wellness Intake Form

Please complete all information on this form and bring it to first visit or you may need to be rescheduled. It may seem long, but most of the questions require only a check, so it will go quickly. You may need to ask family members about the family history. Fill it out to the best of your ability. This information will be kept private in your file. If you need any assistance with this, please let us know. Thank you!  

Current Symptoms Checklist: (check for any symptoms present)

Do you give permission for ongoing regular updates to be provided to your primary care physician?