Please fill in the information below and bring it with you to your first session. Please note: information provided on this form is protected as confidential information.
Parent/Legal Guardian (if under 18): ___________________________________________________ Address: _________________________________________________________________________ Home Phone: ___ _______________________________ May we leave a message? □ Yes □ No Cell/Work/Other Phone: _________________________ May we leave a message? □ Yes □ No Email: ________________________________________ May we leave a message? □ Yes □ No *Please note: Email correspondence is not considered to be a confidential medium of communication. DOB: ______________________________ Age: _______ Gender: ________________ Marital Status: □ Never Married □ Domestic Partnership □ Married □ Separated □ Divorced □ Widowed
Referred By (if any): ________________________________________________________________
History
Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc.)?
□ No □ Yes, previous therapist/practitioner: _________________________________________
Are you currently taking any prescription medication? □ Yes □ No
If yes, please list: __________________________________________________________________________________ __________________________________________________________________________________
Have you ever been prescribed psychiatric medication? □ Yes □ No
If yes, please list and provide dates: _________________________________________________________________________________ _________________________________________________________________________________
General and Mental Health Information
1. 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: _____________________
_____________________________________________________________________________ 2. 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: __________________________________________________________________________________ __________________________________________________________________________________
3. How many times per week do you generally exercise? ___________________________________
What types of exercise do you participate in? ____________________________________________
4. Please list any difficulties you experience with your appetite or eating problems: _______________ _______________________________________________________________________________
5. Are you currently experiencing overwhelming sadness, grief or depression? □ No □ Yes
If yes, for approximately how long?___________________________________________________
6. Are you currently experiencing anxiety, panics attacks or have any phobias? □ No □ Yes
If yes, when did you begin experiencing this? ___________________________________________
7. Are you currently experiencing any chronic pain? □ No □ Yes
If yes, please describe: _____________________________________________________________
8. Do you drink alcohol more than once a week? □ No □ Yes
9. How often do you engage in recreational drug use?
□ Daily □ Weekly □ Monthly □ Infrequently □ Never
10. Are you currently in a romantic relationship? □ No □ Yes
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? ______________________________________________________________________________
11. What significant life changes or stressful events have you experienced recently? _____________ ______________________________________________________________________________ ______________________________________________________________________________
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
Alcohol/Substance Abuse yes / no _______________________
Anxiety yes / no _______________________ Depression yes / no _______________________ Domestic Violence yes / no _______________________ Eating Disorders yes / no _______________________ Obesity yes / no _______________________ Obsessive Compulsive Behavior yes / no _______________________ Schizophrenia yes / no _______________________ Suicide Attempts yes / no _______________________
Additional Information
1. Are you currently employed? □ No □ Yes
If yes, what is your current employment situation? _________________________________________
Do you enjoy your work? Is there anything stressful about your current work? ___________________ __________________________________________________________________________________ __________________________________________________________________________________
2. Do you consider yourself to be spiritual or religious? □ No □ Yes
If yes, describe your faith or belief: _____________________________________________________
5. What would you like to accomplish out of your time in therapy? ____________________________ __________________________________________________________________________________ __________________________________________________________________________________
