Name *
Name
Name of Guardian (if under 18)
Name of Guardian (if under 18)
Birth Date *
Birth Date
Marital Status *
Address *
Address
Phone *
Phone
Mental Health *
Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc.)?
Medication
Are you currently taking any prescription medication?
Psychiatric Medication *
Have you ever been prescribed psychiatric medication?
General Health and Mental Health Information
Current Health *
How would you rate your current physical health?
Sleep Habits *
How would you rate your current sleeping habits?
Are you currently experiencing overwhelming sadness, grief or depression? *
Are you currently experiencing anxiety, panic attacks or have any phobias?
Are you currently experiencing any chronic pain?
Do you drink alcohol more than once a week?
How often do you engage recreational drug use?
Are you currently in a romantic relationship? *
Family History
Alcohol/Substance Abuse *
Anxiety *
Depression
Domestic Violence
Eating Disorders *
Obesity *
Obsessive Compulsive Behavior *
Schizophrenia *
Suicide Attempts *
ADDITIONAL INFORMATION:
Are you currently employed?
Do you consider yourself to be spiritual or religious? *