SPEAK Initiative ON-BOARDING Form 2023

SPEAK Initiative ON-BOARDING FORM

HELLO, SPEAKer! Thank you for choosing this. We are here to help. This form takes approximately 10 minutes. If overwhelmed, contact us. We can do it together. INFORMATION LEGALLY WILL BE KEPT COMPLETELY CONFIDENTIAL
Name

First NameLast Name
Preferred Pronouns

Other
E-mail
Contact Number:

Area CodePhone Number
Can SPEAK Initiative 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
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 support at this time?
Have you ever had counseling or support before?
If yes, was it helpful?
If yes, How long were you in counseling/ a support program?
Anything else you would like to share about your previous 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
Consent for Evaluation and Support
Please Check Below:
Signature
Please verify that you are human
Should be Empty:

SPEAK Initiative ON-BOARDING FORM

PLEASE LIST YOUR CHILDREN AND/OR SIBLINGS BELOW.

Consent for Evaluation and Support