Counseling Intake Form

Counseling Intake Form
INWORLD NAME(THIS IS YOUR SECONDLIFE USER NAME)*
Date of Birth*

MonthDayYear
Date
Marital Status*
Email*
example@example.com
Instagram? *
Employment*
E-mailInstagram DM
Medical History
NoneAllergiesAnemiaAnginaAnxietyArthritisAsthmaAtrial FibrillationBenign ProstaticHypertrophyBlood ClotsCancerCerebrovascular AccidentCronary Artery DiseaseCOPD (Emphysema)Crohn's DiseaseDepressionDiabetesGallbladder DiseaseGERD (Reflux)Hepatitis CHyperlipidemiaHypertensionIrritable Bowel DiseaseLiver DiseaseMigraine HeadachesMyocardial InfarctionOsteoarthritisOsteoporosisPeptic Ulcer DiseaseRenal DiseaseSeizure DisorderThyroid DiseaseOther
NoDailyWeeklyLessFormer User
NoDailyWeeklyLessFormer User
NoDailyWeeklyLessFormer User
YesNo
Please explain the circumstances
YesNo
AdoptedAlcoholismAllergiesAsthmaArthritisBlood DiseaseCAD (Heart Attack)CancerCVA (Stroke)DepressionDevelopmental DelayDiabetesEczemaHearing DeficiencyHyperlipidemia (High Cholesterol)Hypertension (High Blood Pressure)Irritable Bowel DiseaseLearning DisabilityMental IllnessTuberculosisObesityOsteoarthritisOsteoporosisPVDRenal DiseaseOther
Mental Health History
Why you are seeking treatment?*
What do you expect from this counselling?*
YesNo
Average hours of sleep per night*
Please describe any other experiences you have had problems with
Additional comments or concerns
Time? **THIS IS THE TIME THAT YOUR APPOINTMENT WILL BE, IN SECONDLIFE TIME[SLT] NOT REAL LIFE TIME***
Preferred Appointment Date.*

MonthDayYear
Date
*Your signature below indicates that the information you have provided above is truthful.
Signature (Type your Inworld Name below for your signature.)*
Should be Empty:

Counseling Intake Form

Medical History

Mental Health History