Name
*
First Name
Last Name
Address
*
Contact Phone
*
Email Address
*
Marital Status
*
Never Married
Domestic Partnership
Married
Separated
Divorced
Widowed
Gender
*
Male
Female
Other
Prefer not to disclose
DOB
*
MM
DD
YYYY
How did you hear about us?
*
Have you previously received any type of mental health services?
*
(psychotherapy, psychiatric services,
etc.)
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
How would you rate your current physical health?
*
Poor
Unsatisfactory
Satisfactory
Good
Very good
Please list any specific sleep problems you are currently experiencing
*
What types of exercise do you participate in?
*
How many times a week do you generally exercise?
*
Less than 1
1
2
3
4
5
6
7
Please list any difficulties you experience with your appetite or eating problems
*
Are you currently experiencing overwhelming sadness, grief or depression?
*
If yes, for approximately how long?
Are you currently experiencing anxiety, panics attacks or have any phobias?
*
If yes, when did you begin experiencing this?
Have you been diagnosed with a personality disorder(s)?
*
If Yes, please list
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 in recreational drug use?
*
Never
Infrequently
Monthly
Weekly
Daily
Are you currently in a romantic relationship?
*
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?
*
1
2
3
4
5
6
7
8
9
10
Not in relationship
What significant life changes or stressful events have you experienced recently?
*
Alcohol/Substance Abuse
*
If Yes, List Family Member
Anxiety
*
If Yes, List Family Member
Depression
*
If Yes, List Family Member
Domestic Violence
*
If Yes, List Family Member
Eating Disorder
*
If Yes, List Family Member
Obesity
*
If Yes, List Family Member
Obsessive Compulsive Behaviour
*
If Yes, List Family Member
Schizophrenia
*
If Yes, List Family Member
Suicide Attempts
*
If Yes, List Family Member
Are you currently employed?
*
If Yes, what is your currently 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 weaknesses?
*
What would you like to accomplish out of your time in therapy?
*
