What brings you to counseling at this time? Is there something specific, such as a particular event? Be as detailed as you can
What are your goals for counseling?
Have you seen a mental health professional before?
Yes
No
Specify all medications and supplements you are presently taking and for what reason.
If taking prescription medication, who is your prescribing MD? Please include type of MD, name and phone number.
Who is your primary care physician? Please include type of MD, name and phone number.
Do you drink alcohol?
Yes
No
Do you use recreational drugs?
Yes
No
Do you have suicidal thoughts?
Yes
No
Have you ever attempted suicide?
Yes
No
Do you have thoughts or urges to harm others?
Yes
No
Have you ever been hospitalized for a psychiatric issue?
Yes
No
Is there a history of mental illness in your family?
Yes
No
If you are in a relationship, please describe the nature of the relationship and months or years together.
Describe your current living situation. Do you live alone, with others. With family, etc...
What is your level of education? Highest grade/degree and type of degree.
What is your current occupation? What do you do? How long have you been doing it?
Please check any of the following you have experienced in the past six months
Increased Appetite
Decreased Appetite
Trouble Concentrating
Difficulty Sleeping
Excessive Sleep
Low Motivation
Isolation from others
Fatigue/low energy
Low Self-esteem
Depressed Mood
Tearful or crying spells
Anxiety
Fear
Hopelessness
Panic
Other
Please check any of the following that apply
Headache
High blood pressure
Gastritis or esophagitis
Hormone-related problems
Head Injury
Angina or chest pain
Irritable Bowel
Chronic Pain
Loss of Consciousness
Heart Attack
Bone or joint problems
Seizures
Kidney-related issues
Chronic Fatigue
Dizziness
Faintness
Heart Valve Problems
Urinary Tract Problems
Fibromyalgia
Numbness and tingling
Shortness of breath
Diabetes
Hepatitis
Asthma
Arthritis
Thyroid Issues
HIV/AIDS
Cancer
Other
What else would you like me to know?
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