Name
Date
Parent/Legal Guardian (if under 18):
Address:
Home Phone:
Cell/Work/Other Phone:
Email
DOB:
Age:
Gender:
Spouse/Partner Name:
Referred by (if any):
Previous therapist/practiioner:
If yes, please list:
If yes, please list & provide dates:
Please list any specific health problems you are currently experiencing:
Please list any specific sleep problems you are currently experiencing?
How many times per week do you generally exersize?
What types of exersize do you participate in?
Please list any difficulties you experience with your appetite or eating problems:
If yes, for approximately how long?
If yes, when did you begin experiencing this?
If yes, please describe:
If yes, for how long?
On a scale of 1-10 (with 1 being poor and 10 being exceptional), how would you rate your relationship?
What significant life changes or stressful events have you experienced lately?
Family Mental Health History
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 (e.g. father, grandmother, uncle, etc.).
Additional Information
If yes, what is your current employment?
Do you enjoy your work?
Is there anything stressful about your work?
If yes, please describe your faith or belief:
What do you consider to be some of your strengths?
What do you consider to be some of your weaknesses?
What would you like to accomplish out of your time in therapy?
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