Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Main Phone Number
Please enter a valid phone number.
May I leave a voicemail at this number?
Yes
No
May I text this number?
Yes
NO
Additional Phone Number
Please enter a valid phone number.
May I leave a voicemail at this number?
Yes
No
May I text this number?
Yes
No
What is your Email address?
example@example.com
May I Email you?
Yes
No
Patient's Date of Birth
-
Month
-
Day
Year
Date
What is your age?
Marital Status
Single
Married
Divorced
Widow
If you are in a relationship, please describe nature of that relationship and how long together:
Do you have any Children?
Yes
No
Please list your children's names and ages
Describe your current living situation. Do you live alone, with others, own, rent?
What is your current occupation, if any? How long have you been doing it? How many hours per week do you average?
Name of an Emergency Contact
How is your Emergency Contact related to you?
Phone Number of Emergency Contact
Please enter a valid phone number.
May I leave a Voicemail with this contact?
Yes
No
May I text this contact?
Yes
No
How did you get my name as a referral? Was it by an internet source or other provider? Please Explain:
Have you previously received any type of mental health services?
No
Yes
If you received previous mental health services, what was his/her name?
Are you currently taking any medication or supplements?
Yes
No
Please List your medications"
Have you ever been prescribed psychiatric medication?
Yes
No
Please list any psychiatric medications you have taken or are currently taking
Have you ever been hospitalized in a psychiatric setting?
Yes
No
If applicable, where and when were you hospitalized in a psychiatric setting?
Do you have a criminal record?
No
Yes
If you have a criminal record, please explain"
How do you rate your current physical health?
Poor
Unsatisfactory
Satisfactory
Good
Very Good
How would you rate your current sleeping habits?
Poor
Unsatisfactory
Satisfactory
Good
Very Good
How many times per week do you exercise?
Are you currently experiencing any chronic pain?
Yes
No
If you are experiencing chronic pain, please describe:
How often do you drink alcohol?
How often do you engage in recreational drug use?
Select any of the following that you have felt in the past three months:
Sadness
Grief
Anxiety
Panic Attacks
Depression
Nightmares
Insomnia
Excessive Sleep
Excessive Worry
Arguing More
Select any of the following you have felt in the past three months (Part 2):
Increased appetite
Decreased appetite
Trouble Concentrating
Low Motivation
Isolating from Others
Fatigue/Low Energy
Low Self Esteem
Fear
Excessive Spending
Feeling Helpless
Select any of the following you have felt in the past three months (last part):
Feeling Hopeless
Tearful or Crying Spells
Not Bathing
Fear of leaving the house
Racing Thoughts
Suicidal Thoughts
Homicidal Thoughts
Anger
Irritability
What brings you to counseling at this time? Is there a specific event you need help with?
*
What would you like to achieve from your time in therapy?
*
Submit
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