Home
Services
Counseling Services
Mindful Parenting
Resources
New Patient Form
Books To Read
Ted Talks To Watch
Speaking
About
Contact
Home
Services
Counseling Services
Mindful Parenting
Resources
New Patient Form
Books To Read
Ted Talks To Watch
Speaking
About
Contact
Resources
New Patient Form
Books To Read
Ted Talks To Watch
Date
MM
DD
YYYY
Contact Information
Name
*
First Name
Last Name
Email Address
*
Cell Phone
(###)
###
####
Age
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Date Of Birth
MM
DD
YYYY
Emergency Contact Information
Marital Status
Names and Ages of Children
Education Level
Occupation
Areas Of Concern
What issues/concerns are causing you to seek treatment?
Do you have specific goals with regard to your treatment?
Psychological History
Have you ever received mental health treatment before?
When and for how long?
Are you currently taking any medications? If so please list the medications, dosage, length of use, and prescribing physician.
Have you ever been hospitalized for mental or emotional problems? Please describe.
Are you currently having any suicidal thoughts? Please describe.
Have you ever attempted suicide?
Have you ever been the victim of a violent crime? Please describe.
Have you ever been involved in a law suit? Please describe.
Medical History
Have you ever been diagnosed with a serious illness? Please describe.
Do you smoke? If so, how much and for how long?
Do you drink alcohol? If so, on average how much alcohol do you consume in a week?
Do you consume caffeine? If so how much?
Do you currently use recreational drugs? If so, please describe your use.
Have you ever been in a 12 step program? If so, please describe.
Other
Is there anything else you think I should know that hasn't been asked already and pertains to you treatment?
Thank you!
