Please, fill the form and press "Submit" button on the bottom of page.
Filled form will be send to me automatically via e-mail.


 

Name(s):
Date:
Age:
Date of Birth:
Sex: Female
Male
Race/Ethnic Group:
E-mail:
Address:
Phones:
Occupation/Income:
Current Relationship Status/History:
Orientation: Hetero
Gay
Lesbian
Bi
Safe-sex Practices:
Kids (Age/Sex/Custody/Visitation/Problems):
Others in home:
Occupation(s)/Income(s) of others in home:
Referral Source:
Current Situation:
What makes counseling important now:
Specific Nature/Description of Situation(s):
How have you coped with this until now:
Education Level:
Grades:
Last Physical Exam:
Major Health Problems Currently Treated:
Current Medications:
Current Doctor/Clinic:
Have you been: Physically Abused
Sexually Abused
Don't Recall
Did you witness abuse between your parents: Yes
No
Don't Recall1
Did you see abuse between parent(s) and child(ren): Yes
No
Don't Recall
Do you use alcohol: Yes
No
If Yes, how much and how often:
Do you use other drugs: Yes
No
If Yes, what drugs, how much and how often:
Times/Days Available for Appt:
Other Current Mental Health Assistance/Providers:
Other Past Mental Health Assistance/Providers:
May I contact other current/past mental health providers obtain useful information: Yes
No
How did you benefit from past counseling /therapy:
What do you feel got in the way of past counseling/therapy working:

Current Concerns (note all that apply):

Nervousness Suicidal Thoughts Health Problems Temper Unhappiness
Sexual Problems Inferiority Concentration Making Decisions Spirituality
Sleep Problems Relationships Legal Matters Eating Problems Parents
Career Choices Physical Abuse Stomach Probs Being A Parent Boredom/
Emptiness
My Thoughts Nightmares Loneliness Ambition/
Drive 		Friends
Headaches Finances Depression Anger Relaxation
Stress Tiredness/
Energy		 Marriage Separation Memory
Self-Control Work/School Insomnia Children Education
Sexual Abuse Bowel Troubles Shyness Divorce Chronic Illness
Other current concerns:

Current Strengths (note all that apply):

Good Listener Sense of Humor Hard Worker Organized Sympathetic
Responsible Understanding Flexible Sensitive Risk-taker
Emotional Confident Logical Decisive Dependable
Loyal Spirituality Athletic Creative Artistic
High Energy Health Relationship(s) Parents Partner
Education Memory Finances Career Children
Ambition/Drive Recreation Hobbies Pets Belong To Groups
Other current strengths:
What other information you feel might be helpful/useful:
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