Patient Information

Full Name

Sex (for insurance billing)

Female

Male

Self-pay only

Patient Age

Date of birth

Address

City

State

Postal code

Phone *

Email *

Patient Occupation

Preferred form of contact

Email

Text

Phone

Leave a voicemail

If patient is under 18 years of age, enter guardian information below.

Guardian Name

Guardian Date of Birth

Guardian Phone

Emergency Contact Information

Emergency Contact

Relationship to Patient

Emergency Contact Phone Number

Insurance Company/Member ID/Subscriber DOB

Secondary Insurance if applicable

Option 1
Option 2
Option 3
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I give permission to check my benefits

Yes

No

Paying out-of-pocket

Any accessibility needs?

Do you need a translator?

What times are you available?

Mornings

Afternoons

Evenings

Can you commit to bi-weekly sessions

Yes

No

Counselor Preference

Male

Female

How Did You Hear About Us?

Why are you seeking therapy services?

What type of services are you seeking?

Individual Therapy for Adults

Couples Therapy

Famiy Therapy

Child Therapy

Co-parenting

Present Symptoms

Aggression/fights/irritability/violence

Alcohol/drug use/substance abuse

Anxiety/worry

Auditory hallucinations/ hearing voices

Boredom/loss of interest/lack of motivation

Change in apetite/chronic dieting/food concerns/purging/binging/compulsive exercising

Computer addiction

Crying spells

Distractibility/inattention

Fatigue

Fear leaving home

Flashbacks/intrusive or disturbing memories

Gambling

Shame/guilt

Sleep problems/nightmares

Self-harm/suicidal behaviors

Loneliness/withdrawal from people

Impulsivity/risk taking behaviors

Sadness/depression

Work/school problems

Wide mood swings

Suspicion/paranoia/hypervigilance

Social discomfort

Sexual problems

Seasonal mood changes

Relationship problems

Racing thoughts/obsessive thoughts or behaviors

Problems with pornography

Memory loss/problems with memory

Parenting problems

Panic attacks

Low self-worth

Homicidal thoughts

Phobias

Trauma

Emotional abuse

Violence in the home

Homelessness

Teen pregnancy

Neglect

Multiple family home

Parent substance abuse

Placed a child for adoption

Lived in a foster home

Physical abuse

Chronic illness

Financial problems

Foster home

Chronic illness

Physically abused

Sexual abuse

Crime victim

Loss of a loved one

Natural disaster

Medical History - Please list any chronic health conditions, major injuries, surgeries, concussions/head injuries, hospitalizations, or medications etc.

Have you been diagnosed with a mental health disorder before, if so please explain in as much detail as you are comfortable with.

Family History

Depression

Bipolar/Manic Depression

Anxiety

Schizophrenia/Schizoaffective

Autism or Developmental Disorder

Post-Traumatic Stress Disorder (PTSD)

Obsessive Compulsive Disorder (OCD)

ADHD/Hyperactivity

Learning Disorder

Anorexia/Bulimia/Eating Disorder

None or Unknown

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