LET'S CONNECT...Tell me more.
Now that you know a little about me, I'm interested in knowing more about you and your counseling needs. Kindly share what brought you to F.I.T's site by answering the following questions. We look forward to assisting you in your healing journey and ensuring we are a good FIT for you. All information given will be kept confidential.
Client Information
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Gender
Please Select
Male
Female
Age
*
Birth Date
*
-
Month
-
Day
Year
Date
Relationship
What is you relationship status?
*
Married
Never Married
Separated
Domestic Partnership
Widowed
Other
How would you rate your relationship well-being?
*
Not Functioning
1
2
3
4
5
6
7
8
9
No Problems
10
1 is Not Functioning, 10 is No Problems
Please indicate if there is a family history of any of the following conditions;
*
Yes
No
Indicate Family Member
Anxiety
Depression
Substance Abuse / Alcohol
Arrested
Obesity
Schizophrenia
Suicide Attempt
Domestic Violence
Presenting Problem you're seeking to address
*
How would you rate your family relationship?
Not functioning
1
2
3
4
5
6
7
8
9
No Problems
10
1 is Not functioning, 10 is No Problems
History
Have you previously received any type of mental health services?
*
Yes
No
Please list your previous therapist(s)
*
Are you currently on psychiatric medication?
*
Yes
No
Please list psychiatric medicines that you took or are taking currently;
General Health Information
How would you rate your physical health condition?
Very Poor
1
2
3
4
5
6
7
8
9
Excellent
10
1 is Very Poor, 10 is Excellent
How often do you exercise?
None
1
2
3
4
5
6
7
8
9
Very Often
10
1 is None, 10 is Very Often
How would you describe your general appetite?
Very Poor
1
2
3
4
5
6
7
8
9
Very Hungry
10
1 is Very Poor, 10 is Very Hungry
How would you describe your stress level throughout the day?
Very Relaxed
1
2
3
4
5
6
7
8
9
Very Stressed
10
1 is Very Relaxed, 10 is Very Stressed
How would you rate your general happiness and well-being?
1
2
3
4
5
Symptoms
Please answer all of the statements below that describe your concerns
I often experience;
*
fear of many things
guilt
panic attacks
avoiding people
having nightmares
anxiety, nervousness
discomfort in social situations
sexual issues
Other
I often have;
*
suicidal thoughts
memory problems
sleeping disorder
struggled to explain myself to others
obsessive thoughts
violent thoughts
stress and tension
medical concerns
fatigue
work problems
Other
I often feel;
*
lonely
empty
sad
hopeless about the future
excessive guilt
suspicious
Other
Your Availability for Appointment
Please check your available times for a weekly appointment? (Check as many as applies)
Monday
Tuesday
Wednesday
Thursday
Friday
9:00am - 10.00am
10:00am - 11:00am
11:00am - 12:00pm
2:00pm - 3:00pm
3:00pm - 4:00pm
4:00pm - 5:00pm
5:00pm - 6:00pm
6:00-7:00
Submit
Should be Empty: