GETTING STARTED FORM FOR INDIVIDUAL COUNSELING

GETTING STARTED FORM FOR INDIVIDUAL COUNSELING

THIS INFORMATION LEGALLY WILL BE KEPT COMPLETELY CONFIDENTIAL
Name

First NameLast Name
Preferred Pronouns

Other
E-mail
Contact Number:

Area CodePhone Number
Can KYND CONSULTING leave messages on this phone?
In Case of Emergency, Please Contact:

First NameLast Name
Emergency Contact Number:

Area CodePhone Number
Relationship:
Who were you referred by (if anyone)?
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Birth Date:

MonthDayYear
Level of Education

Other
Relationship Status

Other
Are you Employed?
How long have you been employed?
Can you share where you work and what you do?
If you are partnered, can you share your partner's name and occupation?
Do you have children?
FOR TEENS: Do you have siblings?
PLEASE LIST YOUR CHILDREN AND/OR SIBLINGS BELOW.
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Have you ever been hospitalized for psychiatric reasons?
If yes, what were the circumstances? Please include dates:
Please list any physical issues:
If you know, please share the date of your last physical exam.

MonthDayYear
Date
Do you have any sleeping issues?
How many hours of sleep do you get on average?
List any medications you are presently taking and dosage:
Any family members (parents, grandparents, aunts, or uncles) with emotional issues (depression, anger, anxiety, etc)
Any problems with alcohol?
Any problems with drugs?
Do you have current thoughts of suicide?
If yes to the previous question, do you have a plan in place?
Have you EVER had thoughts of suicide?
Have you ever attempted suicide?
If "yes" to the previous question, how many times?
How do you spend time relaxing?
Have you ever had concerns about eating habits?
Reasons for seeking counseling at this time?
Have you ever had counseling before?
If yes, was it helpful?
If yes, How long were you in counseling?
Anything else you would like to share about your previous counseling experience?
Please Check Any of the Following Conditions That Currently Apply to You

Other
Please Check everything that has happened to you in the past two years:

Other
Religious/Spiritual/ Faith Information
Do you attend Church, Synagogue or other religious services?
If yes, how often?
If yes, where do you attend?
What is your perception of God?

0/100
Describe briefly your relationship with spirituality.

0/100
Describe your religious/spiritual upbringing.

0/100
Describe any specific religious/spiritual beliefs/values about which you feel strongly

0/100
Consent for Evaluation and Treatment
Please Check Below:
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Please verify that you are human
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GETTING STARTED FORM FOR INDIVIDUAL COUNSELING

PLEASE LIST YOUR CHILDREN AND/OR SIBLINGS BELOW.

Religious/Spiritual/ Faith Information

Consent for Evaluation and Treatment