Form
Date
-
Month
-
Day
Year
Date
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Info
Name:
Number:
Email:
Additional Info (if needed):
If the initial session is for a minor, do you consent for Angela to access your child?
*
YES
NO
N/A
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?
*
How long do you expect to be in therapy to accomplish these goal (or at least feel like you have the tools to accomplish them on your own)
*
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 smoke or use tobacco? If YES, how much per day?
*
Do you drink caffeine? If YES, how much per day?
*
Do you drink alcohol? If YES, how much per day?
*
Do you use non prescription drugs? If YES, what kinds and how often?
*
Do you have suicidal thoughts?
*
If so, when was your most recent episode?
Have you ever attempted suicide?
*
If so, when was your last suicide attempt?
Do you have thoughts or urges to harm others?
*
If so, when was your most recent episode?
Have you ever been hospitalized for a psychiatric issue(s)?
*
If so, when was your most recent hospitalization for psychiatric issues?
Is there a history of mental illness in your family?
*
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…
*
Height?
*
Weight?
*
Age?
*
Gender?
*
Racial/Ethic Identity?
*
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:
*
Anxiety
Depression
Mood Changes
Anger or Temper
Panic
Fears
Irritability
Concentration
Headaches
Loss of Memory
Excessive Worry
Feeling Manic
Trusting Others
Communicating with Others
Drugs
Alcohol
Caffeine
Frequent Vomiting
Eating Problems
Severe Weight Gain
Blackouts
People in General
Parents
Children
Marriage/Partnership
Friend(s)
Co-Worker(s)
Employer
Finances
Legal Problems
Sexual Concerns
History of Child Abuse
History of Sexual Abuse
Domestic Violence
Thoughts of Hurting Someone Else
Hurting Self
Thoughts of Suicide
Sleeping Too Much
Sleeping Too Little
Getting to Sleep
Waking Too Early
Nightmares
Head Injury
Nausea
Abdominal Distress
Fainting
Dizziness
Diarrhea
Shortness of Breath
Chest Pain
Lump in the Throat
Sweating
Heart Palpitations
Muscle Tension
Pain in Joints
Allergies
Often Make Careless Mistakes
Fidget Frequently
Speak Without Thinking
Waiting Your Turn
Completing Tasks
Paying Attention
Easily Distracted by Noises
Hyperactivity
Chills or Hot Flashes
None of the Above
Family History (please check all that apply):
*
Drug/Alcohol Problems
Legal Trouble
Domestic Violence
Suicide
Physical Abuse
Sexual Abuse
Hyperactivity
Learning Disabilities
Depression
Anxiety
Psychiatric Hospilization
"Nervous Breakdown"
None of the Above
Is there any additional information you would like for me to know?
*
Submit
Should be Empty: