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Email
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Your email
Today's Date
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Name
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First and last name
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Address
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Age
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Date of Birth
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MM
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DD
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YYYY
Gender
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Phone Number
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Contact Preference
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It's OK to send me a text
It's ok to send me emails
It's Ok to leave me a voicemail
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Emergency Contact Person:
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Emergency Contact Phone Number
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Employer
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Job Title
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Hours worked per week
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Social Security #
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Health Insurance Provider
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Primary Card Holder’s name
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Primary Card Holder’s ID
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Primary Card Holder’s Birth Date
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Primary Card Holder’s Phone
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Primary Card Holder’s Address (If different from above)
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Insurance Group, Plan or Policy Number
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Name and phone number of primary physician
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Name and phone number of psychiatrist
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Please list any medications you are taking
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Please list any chronic physical ailments
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Marital Status
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Partnered
Married
Separated
Divorced
Sexual Orientation
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Race/Ethnicity/Nationality
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How did you hear about us?
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Briefly describe (roughly one or two sentences) why you are coming in
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Anything else I need to Know?
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Please provide information about any previous counseling (approximate dates, duration, where, reasons for seeking treatment):
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Please provide the name of any previous psychiatric diagnostics given to you by a mental health professional:
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My family has a history of (please check any/all that apply):
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Alcoholism
Substance Abuse
Depression
Anxiety
Eating Disorders
Bipolar Disorder
Schizophrenia
Emotional Abuse
Physical Abuse
Sexual Abuse
Other psychological problems
Option 12
Suicide
Homicide
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Current Concerns (please check any/all that apply):
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Career
Self-esteem
Relationships
Depression
Anxiety
Physical Health
Cultural/Diversity
Gender
Legal
Financial
Grief
Terminall illness
Substance Use/Abuse
Physical Abuse
Emotional/Verbal Abuse
Sexual Abuse
Harm to Others
Harm to Self
Loss of important relationship
Other concerns
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Are you experiencing suicidal ideation?
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Yes
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