Client Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Name of Parent or Guardian if Under 18

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Cell Phone *

(###)

###

####

Home Phone

(###)

###

####

Have you previously received any type of mental health services? (psychotherapy, psychiatric services, etc?)

Yes

No

Are you currently taking any prescription medication?

Yes

No

Have you ever been prescribed psychiatric medication?

Yes

No

How would you rate you current physical health?

Very Good

Good

Satisfactory

Unsatisfactory

Poor

How would you rate your current sleeping habits?

Very Good

Good

Satisfactory

Unsatisfactory

Poor

Are you currently experiencing sadness, grief or depression?

Sadness

Grief

Depression

Are you currently experiencing panic attacks, anxiety or phobias?

Panic attacks

Anxiety

Phobias

Are you currently experiencing pain?

Yes

No

Do you drink alcohol more than once per week?

Yes

No

Are you currently in a romantic relationship?

Yes

No

Are you currently employed?

Yes

No

Retired

Date

MM

DD

YYYY