Pre-Consultation Form
Welcome to Be Very Resilient! Before our first session, please take some time to complete this form. Your responses will help me better understand your current needs and how we can work together toward your goals. Please note that the information provided will only be used for treatment consideration and that it is HIPAA- compliant. Completion and submission of this form does not establish a client–provider relationship, nor does it constitute legal, financial, or professional advice. Any information shared at this stage is for informational and assessment purposes only.
Patient Information
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Age
Marital Status
*
Please Select
Single
Married
Divorced
Widowed
Other
Gender Identity
Please Select
Choose not to disclose
Female
Transgender Woman (Male-to-Female / MTF)
Male
Transgender Man (Female-to-Male / FTM)
Neither exclusively Male or Female
Genderqueer
Other
Preferred Pronoun
*
Current Employment / Occupation
Parent / Guardian of This Patient
Yes
Please list your current health insurance plan (including the primary and secondary insurance, if applicable):
*
If you do not have health insurance, please indicate how you plan to pay for your appointments (e.g., self-pay):
Current Treatment Request
Treatment currently seeking
*
Psychotherapy (Therapy provided for depression only; 40-minute sessions)
Initiation of psychiatric medications
Medication Management (currently taking prescribed medication(s))
Treatment focus (Therapy services at Be Very Resilient are currently limited to depression.)
*
Current mental/emotional challenges and duration
Who referred you or how did you hear about Be Very Resilient?
*
Mental Health History
Have you ever been formally diagnosed with a mental health condition?
*
Please Select
Yes
No
Mental health diagnoses
*
Current mental health symptoms
Is there a family history of mental health issues?
*
Please Select
Yes
No
Family members and their mental health diagnoses
*
Have you ever been hospitalized for a mental health condition?
*
Please Select
Yes
No
Hospitalization details
*
Have you ever experienced suicidal thoughts or self-harming behaviors?
*
Please Select
Yes
No
Suicidality or self-harm details
*
Hallucinations description
*
Medical History
Current medical diagnoses
*
Current medications
*
Allergies or adverse medication reactions
*
Treatment Goals and Personal Context
What are your goals for treatment?
*
How do you feel about yourself right now?
*
What strengths or coping skills have helped you in the past?
How do you typically respond to stress or difficult emotions?
What is something people often misunderstand about you?
Is there any additional information you would like your provider to know?
Disclosure, Signature, and Date
Acknowledgment
*
I acknowledge that I have read and understood the disclosure.
Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: