Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

Country

(###)

###

####

May I have your permission to thank this person for the referral?

Yes

No

Have You Seen a Psychotherapist Before? *

Yes

No

May I have permission to contact your medical doctor so that he or she can be fully informed and we can coordinate your treatment?

Yes

No

How do you intend to pay for treatment? *

Cash

Check

Credit Card

Insurance

How would you rate your current physical health? *

Poor

Unsatisfactory

Satisfactory

Good

Very Good

How would you rate your current sleeping habits? *

Poor

Unsatisfactory

Satisfactory

Good

Very Good

Are you currently experiencing overwhelming sadness, grief, or depression? *

Yes

No

Are you currently experiencing anxiety, panic attacks, or have any phobias? *

Yes

No

Are you currently experiencing any chronic pain? *

Yes

No

Do you drink alcohol more than once a week? *

Yes

No

How often do you engage in recreational drug use? *

Daily

Weekly

Monthly

Infrequently

Never

Are you currently in a romantic relationship? *

Yes

No

Please indicate if there is a family history of any of the following

Alcohol/Substance Abuse

Anxiety

Depression

Domestic Violence

Eating Disorder

Obesity

Obsessive Compulsive Behavior

Schizophrenia

Suicide Attempts

Are you currently employed? *

Yes

No

Do you consider yourself to be spiritual or religious? *

Yes

No

Date

MM

DD

YYYY