It would help a great deal if you could provide the following basic information and answer the questions below. Please note: information you provide here is protected as confidential. Please electronically submit or bring this form with you to your first session as it will help us to address your concerns quickly.


Name:

Birth Date:

 /   / 
Gender:

Address:

Phone:

–
May we leave a message?

May we send you a Text Message?

E-mail:
May we email you?

*Please note: Email correspondence is not considered to be a confidential medium of communication
Marital Status:

Please list any childrend/age
Have you previously received any type of mental health services (psychotherapy, psychiatric services,
etc.)?

If yes, please specify previous practitioner/therapist
Are you currently taking any prescription medication?

If yes, please list
Have you ever been prescribed psychiatric medication?

if yes please list and provide dates:
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What Concerns led you to make an appointment at this time? What would you like
addressed here?
How would you rate your current physical health?

Please list any specific health problems you are currently experiencing:
How would you rate your current sleeping habits?
How many times per week do you generally exercise?
What types of exercise do you enjoy
Please list any difficulties you experience with your appetite or eating patterns?
Are you currently experiencing overwhelming sadness, grief or depression?

If yes, please explain
Are you currently experiencing anxiety, panic attacks or have any phobias?

If so when did you begin experiencing this?
Are you currently experiencing any chronic pain?

Do you have any history of suicidal thoughts or have you ever tried to harm yourself?
Do you have any history of Psychiatric Hospitalization?
Are you at all concerned about your drinking or drug use?

Are you currently in a romantic relationship?

If yes, for how long?
On a scale of 1-10, how would you rate your satisfaction with this relationship?
What significant life changes or stressful events have you experienced recently?
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In the section below identify if there is a family history of any of the following. If yes, please indicate the
family member’s relationship to you in the space provided (father, grandmother, uncle, etc.).
Alcohol/Substance Abuse Anxiety
Depression
Domestic Violence
Eating Disorders
Obesity
Obsessive Compulsive Behavior
Schizophrenia
Suicide Attempts
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Are you employed?

If yes, what is your current employment situation:
Do you enjoy your work? Is there anything stressful about your current work?
Do you consider yourself to be spiritual or religious?

If yes, describe your faith or belief:
What do you consider to be some of your strengths?
What do you consider to be some of your weakness?
What would you like to accomplish out of your time in therapy?
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