Adult Client Information
First Name:
*
Last Name:
*
Today's Date:
/
Month
/
Day
Year
Date
Phone Number (### ###-####)
-
Area Code
Phone Number
Type a phone
Cell
Landline
Male
Female
DOB:
Age:
Address:
Number and Street
City
*
State
*
Zip Code
*
Email:
*
example@example.com
Additional Contact:
Name
Relationship
-
Area Code
Phone Number
Email: example@example.com
Additional Contact:
Name
Relationship
-
Area Code
Phone Number
Email: example@example.com
Additional Contact:
Name
Relationship
-
Area Code
Phone Number
Email: example@example.com
Messages
If we call you, may we leave a message with someone else?
Yes
No
May we leave a voicemail message?
Yes
No
May we send appointment reminders?
Text
Email
Both
None
Goals for training or primary problem(s) you'd like to improve:
Other providers helping with these issues (please provide contact details)
HOW DID YOU HEAR ABOUT US?
*
*Medical professional
*Mental Health professional
Friend or acquaintance
Facebook
Internet search
Article or ad
Psychology Today
Center for Brain Training website
Informational Seminar
*IF MEDICAL OR MENTAL HEALTH PROFESSIONAL, PLEASE PROVIDE NAME, CITY, STATE
List all prescribed medications/how long on them?/comments
List all supplements/OTC medications/how long on them?/comments
First Name:
Last Name:
Today's Date:
/
Month
/
Day
Year
Date
What brings you here today?
Depression
Anxiety
Sleep
Attention issues
Pain/headaches
Processing or cognitive difficulties
Other
Handedness:
Right
Left
Ambidextrous
Which of these have you experienced?
Concussion or head injury
Very hard hit on the head
Lost of consciousness
Whiplash
None
Explain:
Sleep Patterns:
What time do you typically fall asleep?
How long to fall asleep? (minutes/hours)
Wake up easily?
Yes
No
Sometimes
Never or almost never
Client Name:
Typically sleep through the night, except for getting up to go to the bathroom?
Yes
No
Sometimes
Never or almost never
Wake feeling rested?
Yes
No
Sometimes
Never or almost never
Comments about your sleep:
Are you sensitive to caffeine? (Coffee, Tea, Chocolate, Cola)
Yes
No
Does caffeine make you...
Alert/awake
Jittery/wired/hyper
Relaxed
No effect
Do you use alcohol?
Never
Daily
Occasionally/socially
Does alcohol make you:
Tired
Relaxed
Better
Worse
N/A
Do you have a history of using recreational drugs?
Yes
No
If yes, explain
Do you have any psychiatric or mental health diagoses?
Yes
No
If yes, explain:
Have you had any hospitalizations related to psychiatric or mental heal issue?
Yes
No
If yes, explain:
Have you had any suicidal thoughts or thoughts of self-harm?
Yes
No
Have you had any suicidal plans or plans of self-harm?
Yes
No
Have you had any suicide attempts or attempts of self-harm?
Yes
No
If you had any suicidal thoughts, plans or attempts, explain:
Adult History
First Name:
Last Name:
Provide any important family history issues that may relate to current challenges/symptoms (divorce, disruptions in family, major job challenges, loss of family or friend, etc.)
History of help utilized:
Counseling or behavioral therapy
Exercise or yoga
Medications
Acupuncture/massage
Special diets or nutrition
Comments regarding the help you have used:
How long have you been dealing with your primary issues?
How often do these issues occur?
Every day
Many days each week
Occasionally
What, if anything has helped these issues in the past?
How much do your issues hinder your ability to engage in activities or work or be with family or friends?
Often
Sometimes
Seldom
Never
Which, if any, of the following physical symptoms do you sometimes exprience? (check all that apply)
Sweating hands
Tight chest
Tight stomach
Difficulty breathing
Other
Do you have any history of trauma/being bullied/being physically or emotionally abused?Type a question
Yes
No
If yes, please explain:
Do you sometimes have problems keeping up/being sharp/making decisions?
Yes
No
If yes, please explain:
Check any of these which apply:
Poor self-esteem
Excessively obsessive or worried
Easily overwhelmed
How would you describe yourself?
Do you have excessive sensitivity to light/sound/noise?
Yes
No
This is a "Gut Brain question": Estimate how many rounds of antibiotics you've had since you were born:
Submit
Should be Empty: