Mika Ross Client Information Form
Please submit this form at least 24 hours before your first appointment. Answers will be submitted to a password protected drive that only Mika has access to. If you feel more comfortable with a paper and pen situation, just email a request to Mika's assistant Tina at info@mikaross.com and she'll send you a .pdf ASAP. 
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Today's Date *
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How did you find me? *
First Name: *
Last Name: *
Street Address: *
City: 
State: *
Zip Code: *
DOB: *
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Age: *
Preferred Pronouns: *
Marital Status: *
Phone Number: *
Preferred E-mail: *
How many hours a week do you work outside the home? *
What is your church/denominational background? *
Have you been a previous client of Mika Ross? *
Health
Briefly describe reasons for seeking help, how long has it been a concern, and what you hope to accomplish through therapy.
Describe previous counseling or treatment you received for mental health for family/social problems. (Please list dates of treatment and who provided the treatment)
Have you ever been physically abused, sexually abused or assaulted, and/or raped? (if yes, please indicate below the options that apply to you)
Please comment on any member of your family who suffers from a mental health problem, substance abuse, eating disorder, or has been physically/sexually abused and treatment they have received.
Name of Physician:
Date of last medical exam:
List medications and dosages currently taking:
Family Information
Is either of your parents deceased?
Clear selection
If yes, what was their approximate age of death and your age when the death(s) occurred?
Parent's Marital Status
Clear selection
If divorced, please write years of marriage and your age at the time.
Please list people you consider immediate and/or important family members (for example, parents, siblings, guardians, spouse, children, etc.) and other relevant players in your life (partners,friends):
First name, Relation, Age, Describe this person in one word:
First name, Relation, Age, Describe this person in one word:
First name, Relation, Age, Describe this person in one word:
First name, Relation, Age, Describe this person in one word:
If raised by someone other than parents/step-parents, who were they and how old were you when you lived with them?
How would you describe your physical health?
How frequently do you exercise?
Clear selection
How many hours of sleep have you averaged in the last week?
What three words would you use to describe:
Yourself:
Your Father:
Your Mother:
Your Spouse or Partner:
God:
Please respond to each of the following symptoms by indicating how much of a problem they have been in the last two weeks using the following scale: *
1-Serious Problem
2-Moderate Problem
3-Minor Problem
4-Not a Problem
Depressed Mood
Compulsive Behavior
Anger
Increased Appetite 
Problems with sleep
Poor Judgement 
Decreased Appetite 
Excessive Worry
Sweats / Chills
Nightmares
Irritability 
Significant Weight Gain
Social Withdrawal  
Feelings of Hopelessness 
Thoughts of Death/Suicide 
Loss of interest in things you once enjoyed 
Anxious/Nervous 
Racing Thoughts 
Excessive Feelings of Guild
Chest Discomfort
Panic Attacks
Fatigue/Loss of energy
Difficulty Breathing 
Flashbacks
Difficulty with concentration
Significant weight loss
Couples Information
(If relationship issues have brought you to counseling, Please fill out this section.)
Describe length of relationship
Describe your relationship with your spouse:
In your opinion, when did your relationship stop being fun?
What is your goal for therapy?
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