Elite Mental Health Services LLC.
Confidential Questionnaire
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Age & Date of Birth
*
Place of Employment
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
When would you like to start counseling?
*
What are the preferred days and times for you to have the counseling sessions?
*
How Did you Hear About Us?
*
Have You Been In Counseling Before? If Yes Share When and Reason
*
History of Suicidal Thoughts or Attempt? If Yes, Share When and Details
*
History of Mental Health Diagnosis?
*
Any Medications Associated With Mental Health Diagnosis?
*
History of Psychiatric Hospitalizations?
*
Number of Children? and Ages
*
List People Currently in Your Household.
*
History of Any Kind of Abuse (emotional, sexual, verbal, physical?) Victim, Perpetrator Both?
*
Have You Received Counseling For This? If So, When and For How Long?
*
Why are you seeking mental health therapy?
*
Submit
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