Patient Information Form
Patient Name
*
First Name
Last Name
Date of Birth
*
What brings you to counseling at this time? Is there something specific, such as a particular event? Please describe any difficulties you are experiencing that you want help with. Be as detailed as you can.
When did these difficulties begin?
On a scale from 0-10, how big is the problem? (0= no problem at all, 10= the biggest problem you've ever had in your life)
Have you seen a mental health professional before?
Yes
No
Are you currently a student?
Yes
No
What is the highest level of education that you have earned? Please indicate type of degree and field of study.
Are you currently employed?
Yes
No
How would you rate your physical health?
What do you do in your free time? Please include all extra-curricular activities, hobbies, etc.
How would you rate your sleeping habits (satisfactory or unsatisfactory)? Please describe.
How would you rate your eating habits (satisfactory or unsatisfactory)? Please describe.
Have you experienced any physical or emotional trauma?
Yes
No
Unsure
Have you ever or are you currently experiencing feelings of overwhelming sadness, grief, or depression?
Yes
No
Unsure
Have you ever or are you currently experiencing anxiety, panic attacks, or have any phobias?
Yes
No
Unsure
Please check any of the following you have experienced in the past six months.
Low motivation
Low self-esteem
Depressed mood/sadness
Tearful or crying spells
Anxiety
Fear
Hopelessness
Panic
Unable to enjoy things
Obsessive thoughts
Compulsive bahaviors
Excessive worrying
Sexuality/Gender identity
Racing thoughts
Nervousness/unable to relax
Impulsivity
Difficulty making decisions
See or hear things I shouldn't
Have you ever or are you currently experiencing engaging in self harming behavior?
Yes
No
Unsure
Have you ever or are you currently experiencing suicidal thoughts?
Yes
No
Unsure
Have you ever attempted suicide?
Yes
No
Have you ever had a safety plan put into place by a mental health professional?
Yes
No
Unsure
Have you ever or are you currently having thoughts or urges to harm others?
Yes
No
Unsure
Have you ever been hospitalized for a psychiatric issue?
Yes
No
Is there a history of mental illness in your family?
Yes
No
Unsure
Do you consider yourself to be religious or spiritual?
Yes
No
Unsure
What is your sexuality?
Are you currently going through any life transitions?
Yes
No
Unsure
Are you currently in a relationship?
Yes
No
Who have you lived with in the past? How has this changed or stayed the same?
Describe your current living situation. Do you live alone, with family, with others? Who currently lives in your home?
Are things okay at home right now?
Who would you say is in your support system?
What do you consider your best strengths?
What do you think are your weaknesses?
What causes you to feel frustrated, angry, or hurt?
What have you done in the past to cope with difficult feelings? What have those experiences been like?
What helps you feel happy, calm, and relaxed?
What are your goals for counseling? What do you want to accomplish in counseling? What would you like to see changed as a result of counseling?
Is there anything else you would like me to know so that I can best support you?
What are your strength/conditioning goals?
I am looking for general strengthening for injury prevention and improved physical ability.
I have specific areas that I want to focus on.
If your goals are for specific areas, please describe what you want to improve.
Submit
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