How to find us

Phone: 206-296-4600
TTY Relay: 711

Toll-free: 800-325-6165

Click here to email us

Instructions to submit a Public Records Request

Sample culturally competent intake form

Note: This is not intended to be a complete patient intake instrument, but for incorporation into your existing form.

What is your gender?
Male
Female
Transgendered (check one: MTF FTM)


What is your relationship status?
Single
Legally married
Domestic partner relationship
Divorced / separated
Widowed
Other (please specify):___________________________________


Gender of current sexual partner(s) (circle all that apply)
Male
Female
Transgendered (please specify):________________________
Not currently sexually active with others


Gender of past sexual partner(s) (circle all that apply)
Male
Female
Transgendered (please specify):________________________
Not currently sexually active with others


Are you in a relationship with another person right now?
Yes
No


If yes, is this relationship a good one for you?
Yes
No
Not sure
Not in a relationship right now


Do you need birth control?
Yes
No


If yes, are you currently using birth control?
Yes (please specify type):________________________
No


Do you have any questions about sex or sexuality?
Yes (you may state your question here or we can talk in person)
No


Do you or your partner(s) have any children?
Yes
No


Do any children live in your household?
Yes
No


Do you need to discuss any of the following with us? (check all that apply)
Safety concerns now or a history of physical, sexual or emotional abuse
Getting along with parents
Getting along with friends
Getting along with partner
Privacy/confidentiality
Loneliness, depression, anxiety or problems eating or sleeping
Weight, bodybuilding or eating concerns
Safer sex or sexually transmitted diseases
Pregnancy test or options for starting, ending or continuing a pregnancy
Other (please specify):________________________