____________________________________                ____/____/______                 Female Male
First name                                 Last name                       Date of birth                 F2M M2F Other

___________________________________________(         )_______________ message ok? No Yes
Current address                             zip code          Contact phone cell / home/ office

                                      _____________________________________________________________
Email                                                           Employer/ Type of work/time at this job

_____________________________________________________ _(______)_________________
Emergency contact person relation to you                                     Phone number

Do you adhere to any specific spiritual practice? If so, which?

Civil status: Single Married Co-habitating Partnered Separated Divorced Widowed

Do you have any children living with you?
If yes, how many reside with you?

How many do not reside with you?
Name and Ages in your home:

Do you have any children who don't live with you?

With whom do they reside?
Names and ages not in your home:


What are your top three goals for therapy?
1.

2.

3.

What would you most like to see change as a result of therapy?

How long do you think this issue will take to resolve?

Have you ever been in therapy before? No Yes

If yes, what was that experience like for you?

Do you have insurance you plan to bill or request reimbursement from? No Yes Company_________________________ Member #

Are you currently under a doctor’s care? No Yes,________________________(_____)                    
                                                                         Doctor’s name and phone number
Are you currently taking any type of medication, including herbals? No Yes
If yes, type(s):

Are you currently seeing another therapist? No Yes,_______________________(_____)_____
                                                                                Therapist's name and phone number

**A signed release of info will be needed if you’d like me to contact your other providers**


How many times per week do you typically:
drink alcohol
drink caffeine
smoke
take OTC meds
take vitamins/supplements
exercise
play/recreate
visit with friends


Please answer the following questions with as much information as you feel like sharing today. If you need more space, use the back of the page and number your answers for me:

Do you feel that alcohol or other substances are currently a problem in your life?


Do you feel that spending, gambling, shopping, online gaming or other activities are a problem for you?


Do you feel that violence of any kind is currently a problem in your life?


Are you a survivor of domestic or community violence of any kind (emotional, physical, mental, spiritual, etc.)?


Do you ever feel like giving up, wish you would die, or fantasize about dying?


Are you a survivor of a loved one's (friend, family member, co-worker, etc) suicide or suicide attempt?


Have you recently lost a loved one?


How many hours do you sleep most nights?


Are you happy with your quality of sleep?


Are you happy with your sex life?


Any comments or special needs that you might like me to know about:Add your content here