Name
*
First Name
Middle Name
Last Name
Birth Date
*
Please select a month
January
February
March
April
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June
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September
October
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Month
Please select a day
1
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31
Day
Please select a year
2026
2025
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1926
1925
1924
1923
1922
1921
1920
Year
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Presenting Problem
*
Ethnicity
*
African American
Caucasian
Hispanic
Native American
Asain
Other
Have you been to therapy before?
*
yes
no
Are you currently taking any medications?
*
Yes
No
Please list all medications you are taking.
Do you have a history or are you currently using any substance (ie. illegal drugs, over using any prescription medications, over use of alcohol
Yes
No
Highest level of education?
What is your religion?
Christian
Catholic
Budist
Muslim
Other
Sexual Orientation
Heterosexual
Lesbian
Gay
Bisexual
Transgendered
Asexual
Queer
Other
Gender Identity
Male
Female
Transgendered woman
Transgendered man
Nongender conforming
Other
What are your preferred pronouns?
he/him/his
she/her/hers
Them/their/theirs
Other
Do you have any allergies?
Yes
No
What are you allergic to?
Have you ever been diagnosed with any mental disorder?
Yes
No
What have you been diagnosed with?
Have you ever felt of experienced any of the following?
Type a question
Binging/Purging
Irritabilty
Anorexia
Panic Attacks
Often destroy property
Aggresive Behaviors
Frequently aggressive towards animals
Agitation
Phobias
Often set fires
Have recurrent or persistant thoughts that bother you
Often lose your temper
Excessive anxiety/worry for over 6 months, more days than not.
Difficulty controlling the worry, sleep disturbance, or restlessness.
Re-experience in your mind bad things that have happened to you
Depressed Mood
Hopelessness
Mood Swings
Social Isolation
Grief
Poor Grooming
Appetite Disturbance
Feel depressed most of the day, nearly every day.
Changes in sleep
Elavated Mood
Withdrawn
Feeling Inadequate
Have less interest/pleasure in doing things you usually enjoy doing
Feel fatigued nearly every day.
Feel worthless or excessively guilt most of the time.
Have a difficult time thinking/concentrating, or feel indecisive a lot
Have any beliefs that other people would think are strange.
Ever wanted to hurt or kill yourself.
Currently feel suicidal.
Ever made, or currently have, a suicide plan.
Ever attempted suicide
Delusions
Often lose your temper?
Often feel angry or resentful?
Often argue with adults or authority figures?
Often refuse to comply with rules?
Often blame other people for your mistakes
Ever been diagnosed with ADHD?
Often make careless mistakes?
Often don’t finish assignments.
Often distracted when listening to people
Have trouble organizing tasks?
Avoid things that take you a long time?
Easily distracted by stuff going on around you
Often forgetful
Poor Memory
Often fidget
Often feel restless
Often “on the go,” can’t sit still long
Often talk too much
Have trouble waiting your turn
Often blurt out the answers to questions
Interrupt a lot
Physical Trauma Perpetrator
Physical Trauma Victim
Sexual Trauma Perpetrator
Sexual Trauma Victim
Sexually Acting out
Substance AbuseSexual Dysfunction
Emotional Trauma Perpetrator
Emotional Trauma Victim
Self Injury
Other
Anything else we should know about you?
Family History
Who lives in your household?
Has your mother abused substances in the past/currently?
yes
no
Other
Which substance?
Has your father abused substances in the past/currently?
yes
no
Other
Which substance?
Has your sibling abused substances in the past/currently?
yes
no
Other
Which substance?
Has your mother been diagnosed with a mental disorder in the past/currently?
yes
no
Other
Which substance?
Has your father been diagnosed with a mental disorder in the past/currently?
yes
no
Other
Which substance?
What are your goals for therapy?
*
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