Please fill out this form and bring it to your first session.
1. Name: (Last) (First)
2. Birth Date
3. Age:
4. Gender
5. Pronoun
6. Marital Status Never MarriedDomestic PartnershipMarriedSeparatedDivorcedWidowed
7. Children / age (s)
8. Address: (Street and Number, City, State, Zip)
9. May we leave a message? YesNo
10. Email
11. May I email you ? YesNo
12. Home Phone
13. Cell
14. Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc.) YesNo
15. If yes, last date you assisted? previous therapist / practitioner
17. Are you currently taking any prescription medication ? YesNo
18. Please list each medication you currently take and what is it for
19. Have you ever been prescribed or currently take psychiatric medication? YesNo
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? YesNo
23. How often do you engage recreational drug use? DailyWeeklyInfrequently
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
2. Depression
3. Domestic Violence Eating Disorders
4. Obesity
5. Obsessive Compulsive
6. Behavior Schizophrenia
7. Suicide Attempts:
