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

She/Her/HersHim/He/HisThem/They/TheirsOther
E-mail*
Contact Number:*

Area CodePhone Number
Can SPEAK Initiative leave messages on this phone?*

Yes, you can leave messages at this number.No, please do not leave messages at this number.
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*

SingleMarriedDivorcedActively DatingPartneredLive-in PartnerPrefer not to sayOther
Are you Employed?*

YesNoPrefer not to say
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?*

YesNoPrefer not to say
FOR TEENS: Do you have siblings?*

YesNoPrefer not to sayI am not a teen.
PLEASE LIST YOUR CHILDREN AND/OR SIBLINGS BELOW.
NAME blanks AGE blank GENDER
NAME blanks AGE blank GENDER
NAME blanks AGE blank GENDER
NAME blanks AGE blank GENDER
NAME blanks AGE blank GENDER
NAME blanks AGE blank GENDER
Have you ever been hospitalized for psychiatric reasons?

YesNo
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?

YesNo
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)

YesNoUnsure
Any problems with alcohol?

YesNoUnsure
Any problems with drugs?

YesNoUnsure
Do you have current thoughts of suicide?*

YesNoUnsure
If yes to the previous question, do you have a plan in place?*

YesNoI do not have a plan.
Have you EVER had thoughts of suicide?*

YesNoUnsure
Have you ever attempted suicide? *

YesNoUnsure
If "yes" to the previous question, how many times?
How do you spend time relaxing?*
Have you ever had concerns about eating habits? *

YesNoUnsure
Reasons for seeking support at this time?*
Have you ever had counseling or support before?*

YesNo
If yes, was it helpful?

YesNo
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*

HeadachesNervousnessDizzinessFainting SpellsShynessStomach TroubleRelaxationStressAnxietyFatigueLegal MattersSelf ControlNo AppetiteAngerMemoryMaking DecisionsInsomniaNightmaresSeparationEnergyInferiorityTake SedativesDrug UseLonelinessBowel TroublesMarriageAlcohol UseAllergiesSuicidal ThoughtsSexual ProblemsWorkUnder eatingOvereatingHome ConditionsFriendsConcentrationTemperAmbitionDivorceMy ThoughtsParenthoodHealth ProblemsAgeFinancesMy appearanceFutureSexual AbuseChildrenCareer ChoicesWeightUnhappinessDepressionMood SwingsFearsSelf-esteemPhysical AbuseOther
Please Check everything that has happened to you in the past two years:*

Death of a spouse/partnerMarriage ProblemsDivorceDeath of a family memberFamily Issues (with children/parents/in-laws)Major illness/injury of selfFinancial issuesMove to another city or stateMajor illness/injury of relativeLegal ProblemsBad break upJob dissatisfactionLoss of jobOther
Consent for Evaluation and Support
Please Check Below: *

I hereby give consent for evaluation and support. It is agreed that I may discontinue the evaluation and support at any time and that I am free to accept or reject the solutions provided.I do not give consent.
Signature*

Clear
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