Name
Date of Birth
Referral Source:
Psychology Today
Yellow Pages/YP.com
GoodTherapy.com
Friend/Family
Facebook
Alternative Therapy Directory
Other
Address:
City:
State:
Zip Code:
SSN:
Gender:
Marital Status:
Race/Ethnicity:
Sexual Orientation:
Spiritual Affiliation:
Occupation:
Employer:
Best Phone Number to reach you at:
Is it OK to leave you a message?
Yes
No Is it OK to text you? I will only text you in case of emergency or need to reschedule appointments etc.
No Email:
Contact Person in Case of Emergency:
Phone Number of Emergency Contact Person:
Have you ever had counseling?
No Were you satisfied with that experience?
No If not, please explain:
What issues were addressed at that time?:
Primary Care Physician:
Psychiatrist:
Are you taking any medication?
No If yes, please list the name and the dose:
Other ongoing medical/physical problems?
Previous hospitalizations (Date, location, treatment):
Have you ever had suicidal thoughts?
No If yes, how often?
Have you ever attempted suicide?
No If yes, how many times?
Date of last attempt:
Please give a brief description of your current difficulties:
What would you like to accomplish during your time in counseling?
Please check any current or recurring symptoms:
Asthma Anxiety/Nervousness Alcohol Abuse Depression Substance Abuse Eating Disorder Guilt Difficulty Sleeping Sexual Abuse Excessive Fears Compulsions Physical Abuse Emotional Abuse Headaches Weight Loss/Gain Body Image Problems Crying Excessive Sleeping Sexual Concerns Strange Thoughts Difficulty Concentrating Social Isolation Excessive Anger Recent Loss/Trauma Feelings of Inferiority Mood Swings Emotional Outbursts Disturbing Dreams Fatigue or Low Energy Hearing Voices Other
