The Throne and Therapy

The Throne and Therapy

All information is held strictest confidence. At no given point is information disclosed or shared without client’s written consent. You may choose to skip answering any question you feel impinges on personal information you do not wish to disclose.
Full Name

First NameMiddle NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Birth Date

MonthDayYear
E-mail
example@example.com
Phone Number
Format: (000) 000-0000.
Emergency Contact

First NameLast Name
Phone Number
Format: (000) 000-0000.
Have you been affected by HIV ( This may be related to individual, family and/or friend.)
Therapy History

Other
If you had a bad experience with therapy, please share what contributed to this experience?
What has changed in your life at this time for you to want therapy?
Who is your support system? Are they consistent with staying in contact with you?
Please rate your level of depression on a scale from 0-10.
Please rate your level of anxiety on a scale from 0-10.
Please rate your level of agitation on a scale from 0-10.
Please rate the frequency/severity of any panic attacks that you have experienced lately on a scale from 0-10.
Please rate the how often you skip, miss, forget, or don’t take doses of prescribed medication. (0-3 never or seldom miss doses/ 4-7 sometimes miss doses/ 8-10 frequently miss doses or not taking)
Hours of sleep
How can therapy help reach your goals? Please share what your goals are.
What is your view of being in therapy?
Are you currently seeing any other healthcare professional?
At what time is best for you to complete therapy sessions? Select all that apply.
Should be Empty: