Initial Questionnaire

Initial Questionnaire – Adults

Please complete this form accurately to help us provide you with the best care at El Consultorio, PLLC.
14901 E Hampden Ave. Suite 390. Aurora, CO 80014

Phone: 720-260-4115

Fax: 720-836-6394

info@el-consultorio.com

el-consultorio.com
Please remember it is very important not to complete this information without the patient's authorization. Thank you.
For myselfFor someone else
Name of the person other than the patient*
Relationship to the patient*
Patient Information

Admission Questionnaire Instructions. Please complete the admission questionnaire in full before your first appointment. The information you provide will help us better understand your history, current concerns, and goals for the therapeutic process. We invite you to answer each question with as much honesty and detail as you feel comfortable. There are no right or wrong answers. If a question does not apply to you, you may write "N/A." If you are unsure about an answer, provide your best estimate. If you have any questions while completing the questionnaire, please do not hesitate to contact our office. We will gladly assist you.
Client's Legal Full Name*

First NameLast Name
Preferred Name
Date of Birth*

MonthDayYear
Date
Age
Age*
FemaleMaleOther
Address*

Street Address

Street Address Line 2
CityState / ProvincePostal Code / Zip
Email*
example@example.com
EmailText MessagePhone Call
By providing your communication preferences, you authorize El Consultorio and its staff to contact you via email, text message, or phone calls.
Main Reason for Your Consultation or Concern
Please describe in detail the main reason for your consultation, including any relevant concerns. Also indicate how these symptoms have impacted your daily life.*
MildModerateSevereExtremePrefer not to answer
How have these concerns impacted your daily life?*
0–6 months6–12 monthsMore than 1 year
YesNo
In personVirtualHybrid
Relationships and Family
Describe your current family and/or partner dynamics
History of relationship with parents/caregivers
Medical and Health History
Date of Last Medical Visit

MesDíaAño
Fecha
Date of Last Dental Visit

MesDíaAño
Fecha
Have you had any major hospitalizations or accidents? Please describe.
YesNo
If yes, describe your previous therapy experience, name of your previous therapist, and approximate dates
YesNo
If yes, describe the problems with substances/eating
Current status regarding substances
Current medications and dosages
TobaccoAlcoholDrugsCaffeineSleeping medicationsGamblingOtros
Employment and Finances
Describe your current work situation
Describe your current financial situation
Stress and Well-being
LowModerateHighVery high
What are the main sources of stress in your life right now? (e.g., partner or marriage concerns, financial stress, work or professional difficulties, family dynamics, health problems, unmet expectations, or other life situations). Please describe:
How do you usually cope with or manage stress? Please describe the strategies or behaviors you use:
Lifestyle
Please describe your hobbies, interests, and any community involvement that gives you connection, purpose, or enjoyment:
Do you currently exercise or engage in physical activity? If yes, please describe the type of activity, frequency, and average duration of each session:
Present Problems and Concerns

Please select all behaviors or symptoms that concern you or cause you distress in your daily life.
Anxiety, worry or stressPanic attacksSadness, depression or hopelessnessMood swings or irritabilityLow motivation or loss of interestFeelings of guilt, shame or low self-esteemDifficulty concentrating or memory problemsSleep problems or fatigueChanges in appetite or weightIsolation or difficulty in social situationsFrequent conflicts with othersProblems at school or workRacing, obsessive or intrusive thoughtsThoughts of self-harm or deathImpulsivity or difficulty controlling behaviorsUse of alcohol or drugsProblems with technology (cell phone, computer)Problems with food, gambling or sexualityUnusual experiences (hallucinations, paranoia)Traumatic memories or nightmares
Public Benefits and Insurance
SSISSDIMedicaidMedicare
Advanced Directives
El Consultorio, PLLC recognizes the importance of advance directives. As an outpatient mental health practice, we do not provide life support medical treatment and therefore do not implement or act upon medical instructions related to future medical care decisions in case you are unable to communicate.
YesNo
YesNo
YesNo
Emergency Contact
In case of an emergency, El Consultorio PLLC staff may contact the following authorized person to receive information. This person must be someone other than the person accompanying or bringing you to the session and should not be present during the appointment. Please provide the name of a trusted person who can be contacted if necessary. By providing emergency contact information, this person authorizes us to contact the emergency contact. Also, this person should not be from the same household, such as mom or dad.
Full name of contact person*

First NameLast Name
Relationship to patient*
Phone number of contact person*
Please enter a valid phone number.Format: (000) 000-0000.
Email of contact person*
example@example.com
Medical Insurance
Primary Medical Insurance Type*
Policy Number*
Medical Insurance Photo - Front
Medical Insurance Photo - Back
Secondary Medical Insurance
It is very important that you inform us if you have additional insurance. Failure to provide information about your secondary insurance may cause billing problems. If this happens, you could be responsible for the full payment of sessions, as insurance companies may deny or withdraw payments if they do not receive correct information about your coverage. If your insurance denies charges because there is another plan that should be the primary insurance, you will be responsible for outstanding amounts, including possible external billing charges or bank fees. We ask that you inform us about any other medical insurance you have, now or in the future, to avoid inconveniences.
YesNo
Secondary Medical Insurance Type*
Secondary Policy Number*
Secondary Medical Insurance Photo - Front
Secondary Medical Insurance Photo - Back
I certify that all information provided in this questionnaire is true and correct to the best of my knowledge.
Clear
MonthDayYear
Should be Empty:

Initial Questionnaire – Adults

Patient Information

Main Reason for Your Consultation or Concern

Relationships and Family

Medical and Health History

Employment and Finances

Stress and Well-being

Lifestyle

Present Problems and Concerns

Public Benefits and Insurance

Advanced Directives

Emergency Contact

Medical Insurance

Secondary Medical Insurance