Personal Information Personal Information

Name

Date

Name of Parent/Legal Guardian (if under 18):

Address

Home Phone

Can I leave you a message? Can I leave you a message? Yes No

Cell/Work/Other Phone:

Can I leave you a message? Can I leave you a message? Yes No

Email

Can I leave you a message? Can I leave you a message? Yes No

DOB

Age

Gender Gender Man Woman Transgender Non-binary/non-conforming Prefer not to respond

Martial Status: Martial Status: Never Married Domestic Partnership Married Separated Divorced Widowed

Referred By (if any):

History History

Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc.)? Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc.)? Yes No

If Yes, previous therapist/practitioner:

Are you currently taking any prescription medication? Are you currently taking any prescription medication? Yes No

If yes, please list:

Have you ever been prescribed psychiatric medication? Have you ever been prescribed psychiatric medication? Yes No

If yes, please list and provide dates:

General and Mental Health Information General and Mental Health Information

How would you rate your current physical health? (Please circle one) How would you rate your current physical health? (Please circle one) Poor Unsatisfactory Satisfactory Good Very Good

Please list any specific health problems you are currently experiencing:

How would you rate your current sleeping habits? (Please circle one) How would you rate your current sleeping habits? (Please circle one) Poor Unsatisfactory Satisfactory Good Very Good

Please list any specific sleep problems you are currently experiencing:

How many times per week do you generally exercise?

What types of exercise do you participate in?

Please list any difficulties you experience with your appetite or eating problems:

Are you currently experiencing overwhelming sadness, grief or depression? Are you currently experiencing overwhelming sadness, grief or depression? Yes No

If yes, for approximately how long?

Are you currently experiencing anxiety, panics attacks or have any phobias? Are you currently experiencing anxiety, panics attacks or have any phobias? Yes No

If yes, when did you begin experiencing this?

Are you currently experiencing any chronic pain? Are you currently experiencing any chronic pain? Yes No

If yes, please describe

Do you drink alcohol more than once a week? Do you drink alcohol more than once a week? Yes No

How often do you engage in recreational drug use? How often do you engage in recreational drug use? Daily Weekly Monthly Infrequently Not applicable

Are you currently in a romantic relationship? Are you currently in a romantic relationship? Yes No

If yes, for how long?

On a scale of 1-10 (with 1 being poor and 10 being exceptional), how would you rate your relationship?

What significant life changes or stressful events have you experienced recently?

Family Mental Health History Family Mental Health History

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 (e.g. father, grandmother, uncle, etc.) Please Circle List Family Member 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 (e.g. father, grandmother, uncle, etc.) Please Circle List Family Member

Alcohol/Substance Abuse Alcohol/Substance Abuse Yes No

Anxiety Anxiety Yes No

Depression Depression Yes No

Domestic Violence Domestic Violence Yes No

Eating Disorders Eating Disorders Yes No

Obesity Obesity Yes No

Obsessive Compulsive Behavior Obsessive Compulsive Behavior Yes No

Suicide Attempts Suicide Attempts Yes No

Additional Information Additional Information

Are you currently employed? Are you currently employed? Yes No

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? Do you consider yourself to be spiritual or religious? Yes No

If yes, describe your faith or belief:

What do you consider to be some of your weaknesses?

What do you consider to be some of your strengths?

What would you like to accomplish out of your time in therapy?

Are you interested/open to using holistic solutions or practices as a part of your counseling? Are you interested/open to using holistic solutions or practices as a part of your counseling? Yes No