Name:

Email:

Phone Number:

Date of Birth:

How did you hear about us?: —Please choose an option—InstagramGoogle SearchYelpFriendAnother ProfessionalTiktokOther

Tell us about what you're dealing with

What is your availability?MorningAfternoonEvening

Are there any specific services or specialties you’re interested in?Virtual SessionsIndividual TherapyCouples or Family TherapyEMDRLGBTQ+BIPOCPlay TherapyTherapy GroupsIn Community ServicesMentoringOther

Is there anything else you would like us to know?

Are you interested in Teletherapy or In Person Services? —Please choose an option—Teletherapy OnlyIn Person TherapyEither

Do you have a preference in therapist?

How would you like us to contact you?EmailPhoneNo preference

Please upload a copy of your Insurance Card:

Insurance Card (Front):

Insurance Card (Back):

What is the reason you are coming in for counseling? Is there something specific, such as a particular event? If this is due to a specific event, when did it start or happen? How is your life affected by this issue? Please be as detailed as you can.

What do you think you need the most help with right now?

Please rank your concerns in the following areas on a scale of 1 to 10 (0 = No problems and 10 = Major problems). You may use the same number for more than one area:

Depression 012345678910

Anxiety/Worry 012345678910

Parents 012345678910

Friends 012345678910

Sex 012345678910

School 012345678910

Substance Use 012345678910

Legal 012345678910

Anger Issues 012345678910

Suicidal Thoughts 012345678910

Trouble Eating Food 012345678910

Are you currently in school? If so, what grade are you in?

When did/do you attend class?

If you are attending, what is school like for you?

If attending, what school do you go to?

What was your grade point average last report card?

Are these grades better or worse than usual?

Have you ever attended any special classes (i.e., resource program, gifted programs)?

Do you have a learning disability? If so, what is the disability?YesNo

During the past school year, about how many days were you absent when you were supposed to be in school?

Have you ever been suspended or expelled from school? If yes, please share additional details.

Have you ever been in trouble at school related to an alcohol or other drug problem? If yes, please share additional details.

What do you like to do for fun or enjoyment? Do you have any hobbies that you enjoy regularly? Do you prefer your enjoyment alone, with others, or both?

Are you sexually active?YesNo

Do you practice safe sex?YesNo

Do you currently drink alcohol? If so, describe the type, amount, and how often (daily, weekly, monthly, etc.).YesNo

Do you smoke cigarettes or use any nicotine products? If so, what and how often?YesNo, I don't use any nicotine products.

Do you currently use recreational drugs? If so, describe type, amount, frequency.YesNo

Has your drinking or drug use ever caused problems in your family, relationships, or job?YesNo

Have you ever been arrested for a D.U.I or other drug related offense? If yes, please give dates and details.YesNo

Is it difficult for you to stop or control the amount you drink or use?YesNoN/A

If you feel you have a problem with alcohol or drugs, would you like help?YesNo

Please check any symptoms that you currently experience or have experienced, and indicate when you experienced them:HeadachesRestlessnessDizzinessPainExcessive AngerLess Need for SleepExcess EnergyElated MoodExcessive SpendingRacing ThoughtsFeeling IrritableFeeling WiredMood SwingsGrandiose ThoughtsImpulse BehaviorConfusionAlcohol CravingDrug CravingEating ProblemsWeight GainWeight LossLoss of AppetiteDifficulty Getting to SleepAppetite ChangesDifficulty Staying AsleepFrequent NightmaresLow EnergyUnable to Have FunDecreased PleasureFeeling WorthlessFeeling HopelessFeeling IsolatedSuicidal ThoughtsSuicidal PlansAttempted SuicideCrying FrequentlyAnxietyFrequent WorryingFearsPanic AttacksAvoiding Places of Situations due to Fear or Panic/AnxietyConcentration ProblemsFeel that Others are Plotting Against YouConstant Suspicion or DistrustHearing Voices that Others do not HearSeeing Things Others do not SeePhysical AbuseSexual AbuseEmotional/Verbal AbuseSexual ProblemsRelationship ProblemsFamily ConflictFears of Losing ControlUnwanted Thoughts or BehaviorsFeeling the Need to do or Repeat ThingsObsessive/Repetitive ThoughtsUnusual ThoughtsStrange ExperiencesThoughts of Someone Physically Harming YouThoughts of Physically Harming SomeoneViolent or Aggressive Behavior

Have you seen a mental health professional before? If so, please specify dates, the reason for counseling, and your experience. What was your diagnosis, if any? YesNo

If applicable, list all psychotropic medications you are currently taking, for how long, and for what reason. What is the dosage of each? What time of day do you take it (morning, evening, bedtime)? Does it help?

If taking prescription medication, who is your prescribing doctor? Please include type of doctor, name, and phone number.

Do you have, or have you ever had, suicidal thoughts?If yes, when? How would you end your life?No, I have never had suicidal thoughts.

Have you ever attempted suicide? Please list all attempts and your age when each happened, starting from the most recent event to the oldest event.If yes, when? How did you do it?No, I have never attempted suicide.

Have you ever been hospitalized for a psychiatric issue? If yes, please describe why, when, and the length of your stay.YesNo, I have never attempted suicide.

Please check any symptoms that you currently experience or have experienced, and indicate when you experienced them:Learning Challenges/DisabilityDepression/ Bipolar DisorderAlcoholism/Drug AddictionAnxiety/Panic AttacksTrauma (sexual assault, combat, abuse, etc.)Suicide AttemptsEating Disorders (Anorexia/Bulimia)Hyperactivity/ADHDOther

Please describe your relationship with your mother.

Please describe your relationship with your father.

Do you have siblings? If so, please describe your relationship with them.YesNo

If you are in a relationship, please describe the nature of the relationship and months or years together.

Who do you know that you would consider your closest sources of support or your "inner circle" (e.g., grandparent, aunt, uncle, friend, cousin, teacher, etc.)?

Please share anything else that you would like us to know.