Background Information
Spouse Name (if applicable)
Spouse Phone (if applicable)
Parent Information
Parent Name (if applicable)
Parent Phone (if applicable)
Additional Family Members Living With You
Family History
Have any of your biological relatives had concerns similar to yours, or had any other psychiatric or emotional difficulties? (required) Yes No If yes, which relatives and what kind of concerns/difficulties
Emergency Contact
Name Phone Number Relationship
Presenting Concern
Please describe briefly the concern or situation, which led you to seek services at this time (required)
How long has this been a concern? (required)
Have you experienced this type fo concern before? (required) Yes No If so, when?
Have you had any significant events, either positive or negative, occur recently or in a notable amount of time, such as job/school changes, death(s), changes in finances, living situation, illness, infertility, etc?
Physician Information
Physician Name
Physician Phone Number
Therapeutic Concerns
Are you currently seeing a counselor, therapist, psychologist, or psychiatrist? (required) Yes No If yes, who?
Have you ever had counseling before? (required) Yes No If so, when and why? Was it helpful? Yes No If not, why not?
Have you ever had medication prescribed for psychiatric or emotional difficulties? (required) Yes No If so, please list
Have you ever been physically, sexually, or emotionally abused? (required) Yes No If yes, briefly describe
Have you ever been hospitalized for mental or nervous problems? (required) Yes No If yes, when and where
Are you experiencing any issues related to sexuality (i.e. sexual identity, compulsive pornography use, desire, performance, etc.)? (required) Yes No If yes, please explain
Have you ever attempted suicide? (required) Yes No If yes, how and when? Are you suicidal now? (required) Yes No
Alcohol & Substance Concerns
How often do you drink alcohol? (required)
Have you ever been arrested for driving under the influence (DUI)? (required) Yes No
Do you smoke or use tobacco? (required) Yes No If yes, how much?
Do you use recreational drugs? (required) Yes No If yes, what drugs do you use and how often?
Do you have any concerns about alcohol/drug usage by members of your family? (required) Yes No If yes, please explain
Legal Concerns
Are you currently involved or expected to be involved in any court related matters? (required) Yes No If yes, please describe
Religious & Spiritual
Do you consider yourself spiritual? (required) Yes No Do you consider yourself religious? (required) Yes No Comment?
Do you currently express this spirituality through religious practice? (required) Yes No Comment?
Would you like spirituality included in your counseling? (required) Yes No Church affiliation
