Name
*
First Name
Last Name
Email
*
Name of Parent or Guardian for under 18 years old
First Name
Last Name
Birthdate
MM
DD
YYYY
Phone
(###)
###
####
May we leave a message on your phone voicemail?
Referred by (if any):
First Name
Last Name
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
Please list any specific health problems you are currently experiencing:
Please list any specific sleep problems you are currently experiencing:
How many times per week do you generally exercise?
What types of exercise to you participate in?
Please list any difficulties you experience with your appetite or eating patterns:
Are you currently experiencing overwhelming sadness, grief or depression?
If yes, indicate for how long
Are you currently experiencing anxiety, panic attacks or have any phobias?
If yes, when did you begin experiencing this?
Are you currently experiencing any chronic pain?
If yes, please describe
Do you drink alcohol more than once a week?
How often do you engage recreational drug use?
Are you currently in a romantic relationship?
If yes, indicate how long
What significant life changes or stressful events have you experienced recently?
Please identify and check if there is a family history of any of the following:
If you checked one of the above except none, please indicate the family member’s relationship to you in the space provided (uncle, father, grandmother etc. )
Are you currently 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, please describe your faith or belief
What do you consider to be some of your strengths?
What do you consider to be some of your weaknesses?
What would you like to accomplish out of your time in therapy?
Date completed this form
MM
DD
YYYY
