Please enter your information. Please be as detailed as you can so that we can find you the best fit therapist. Name: * Email: * Phone Number: * City and State: * What led you to seeking counseling services at this time? Were you referred by anyone? FriendsPhysicianTreatment CenterGoogleBingFacebookInstagramTwitter (X)LinkedInSnapchatTikTokOthers How long have you been dealing with this problem? Next What are your goals for counseling? Have you seen a mental health professional before? (Licensed Professional Counselor, Licensed Clinical Social Worker, Psychologist, Licensed Marriage and Family Therapist) If yes, please list physician's contact information YesNo Please list all medications and supplements. List reason for taking each one. BackNext If taking prescription medications, please include the name of your prescribing provider and their credentials (NP, APRN, PA, DO, or MD). Please include their contact information. Who is your primary care physician? Please include name and phone number. Do you drink alcohol? YesNo If Yes, please specify how much per week BackNext Do you use recreational drugs? YesNo If Yes, please specify how many times a week Have you ever had suicidal thoughts? YesNo Have you ever attempted suicide? YesNo Do you have thoughts or urges about hurting others? YesNo Have you ever been hospitalized for a psychiatric issue? YesNo Is there a history of mental illness in your family? YesNo BackNext If you are in a relationship, please describe the nature of the relationship and months or years together. Describe your current living situation. Do you live alone or with others? (Friends, family, significant other, roommate, etc...) What is your level of education? Highest grade or degree achieved? * BackNext What is your current occupation? What does your typical workday look like? How long have you been at your current job? Please check any of the following issues you have experienced in the past 6 months. Increased AppetiteDifficulty SleepingFatigue/Low EnergyTearful or Crying SpellsHopelessnessDecreased AppetiteLow MotivationLow Self-EsteemAnxietyPanicTrouble ConcentratingIsolation from OthersDepressed MoodFearOther If Other is checked, please specify Please check any of the following that apply. HeadacheHormone-Related ProblemsIrritable BowelHeart AttackKidney-Related IssuesFaintnessFibromyalgiaDiabetesHIV/AIDSHigh Blood PressureHead InjuryChronic PainBone or Joint ProblemsChronic FatigueHeart Valve ProblemsNumbness of TinglingHepatitisCancerGastritis/EsophagitisAngina or Chest PainLoss of ConsciousnessSeizuresDizzinessUrinary Tract ProblemsShortness of BreathThyroid IssuesOther If Other is checked, please specify Have you or any family member been seen by someone in this practice before? If yes, please provide their name. Have you or any family member been seen by someone in this practice before? If yes, please provide their name. What else would you like me to know? The capital of Japan? Back Δ
