Please complete this section only if you are under the age of 18 years.
Please complete this section only if you are married or in a committed relationship.
If you give us permission to contact your Primary Care Physician to coordinate care, please sign your name and date below:
If you give us permission to contact your Psychiatrist or Psychiatric NP to coordinate care, please sign your name and date below:
1. Problems between husband/wife, romantic partners
2. Family problems, parenting problems, children’s behavior, problems with parents, brothers, sisters
3. Problems with social skills, social life, finding friends, getting along with others
4. Trouble coping with emotions such as anger, depression, anxiety, stress, withdrawal, etc.
5. Problems with sexual functioning
6. Problems with alcohol, drugs, food, or gambling
7. Legal problems, such as divorce, custody, arrests
8. Home management, care of the house & family members
9. Health Concerns
10. Money and budgeting problems
11. Job or school related problems, such as job dissatisfaction, poor performance, unemployment