New Patient Questionnaire
Please answer the following questions as completely as you can. This will help your therapist customize your treatment specifically for you.
Name
First Name
Last Name
Why are you seeking help now?
Have you seen a mental health professional before? If so, please describe the issue.
Have you ever been hospitalized for a mental health condition?
Yes
No
Has anyone in your family ever received mental health treatment, been hospitalized for a mental health concern or gone to rehab? If so, please describe.
Do you have any current or prior medical issues?
Please specify any/all medications you are prescribed or are taking, for what reason, and the dosages.
Do you now or have you ever used alcohol, tobacco, recreational drugs or medicines other than as prescribed? If so, please describe.
Who is in your family? What is your relationship with them like?
What social activities and/or relationships do you engage in?
What spiritual factors and cultural influences are important to you?
What was life like when you were growing up, both at home and at school?
What significant education or work/volunteer experiences have you had?
What is your current occupation? What do you do? How long have you been doing it?
Describe your current living situation. Do you life alone, with others, with family?
Do you have any current or prior legal issues? Please include divorce or custody issues.
What strengths and abilities do you bring to sessions? What needs or preferences do you have that will help us be successful?
What else would you like me to know?
Who is your emergency contact person?
First Name
Last Name
What is his/her/their phone number?
Please enter a valid phone number.
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