Please fill out this form and bring it to your first session.
1. Name: (Last) (First)
2. Birth Date
6. Marital Status
Never MarriedDomestic PartnershipMarriedSeparatedDivorcedWidowed
7. Children / age (s)
8. Address: (Street and Number, City, State, Zip)
9. May we leave a message?
11. May I email you ?
12. Home Phone
14. Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc.)
15. If yes, last date you assisted? previous therapist / practitioner
17. Are you currently taking any prescription medication ?
18. Please list each medication you currently take and what is it for
19. Have you ever been prescribed or currently take psychiatric medication?
20. Please list and provide dates
21. Name and contact information of physician who prescribed it?
22. Do you drink alcohol more than once a week?
23. How often do you engage recreational drug use?
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 (father, grandmother, uncle, etc.).
1. Alcohol/Substance Abuse Anxiety
3. Domestic Violence Eating Disorders
5. Obsessive Compulsive
6. Behavior Schizophrenia
7. Suicide Attempts: