New Client Intake & Assessment

  • New Client Welcome to Wellness Form

    Please  complete this form and sign. You do not have to answer every question. Only answer what you feel comfortable with, sign, and submit. Answers to the questions listed here only serve aid in assessing treatment paths.  Thank you!
  • Date
     - -
  • Current  Symptoms Checklist:  (check once for any  symptoms present, twice  for major symptoms)
  • Past  Psychiatric  History: Outpatient  treatment ?
  • Psychiatric  Hospitalization?
  • Psychiatric  Medications: please indicate past and present medications
  • Check if you have ever tried the following
  • Tobacco History:  How you ever smoked cigarettes?
  • Currently?
  • Relationship Status
  • How  would  you identify  your sexual orientation?
  • How would you prefer to be addressed (Which Pronoun)?
  • What is your current living Situation?

  •                                            Nutritional Analysis 

     ( For Those Seeking Help with Diet and Nutrition Only,if not interested, please Skip this Section and move on to sign and submit the form. )

     

  • On a scale of 1 (not willing) to 5 (very willing), please indicate your readiness/willingness to do the following: 

     

    To improve your health, how ready/willing are you to… 

     

  • Rows
  • Do you eat more:
  • Please indicate the materials you use for cooking and food storage:
  • If you follow a special diet/nutritional program, check the following that apply:
  • Which meals do you eat regularly, check all that apply:
  • Date
     - -

  •                                  MindBeingWell: The Wellness Project                                                                                                    MindBeingWell@welltherapy.healthcare/(678)250-3093

                http:// www.welltherapy.healthcare

     

     

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