Date of Birth
Is it OK to contact you at home?
OK to leave a message?
Is it OK to contact this number?
OK to leave a message?
Please briefly describe the problems you are experiencing.
What has happened to cause you to seek help now?
What do you hope to be able to do or achieve as a result of treatment?
Do you currently have thoughts of harming yourself?YesNo
Have you in the past?YesNo
If Yes, how long ago?
Do you currently have thoughts of wishing you were dead?YesNo
Do you currently have urges to hurt, harm, or kill someone else?YesNo
If yes, whom?
Name, address, phone number and fax number of your Psychiatrist:
Have you ever been treated, or have you ever had previous therapy/counseling of any kind?YesNo
If yes, when, with whom, and for how long?
Have you been hospitalized for emotional problems?YesNo
Or for substance abuse problems?YesNo
If yes to either of above, please state when, where, and for how long were you hospitalized (Please consider having recent records forwarded to this office),
Have you ever experienced a problem with alcohol, drugs, or prescription medications?YesNo
If yes, please explain
List the name of your children and their ages
Whom were you raised by (Please indicate their name)?
Describe your relationship with your parents briefly
Has anyone in your family ever attempted or committed suicide?YesNo
If yes, please explain:
Marital/relationship status ( Check one )MarriedLive with PartnerSingleSeparated/DivorcedWidowed
Have you ever been abused mentally or physically by a romantic partner?YesNo
Does this apply to your current relationship?YesNo
Do you feel safe?YesNo
Check all that apply: EmployedRetiredDisabledStudentHomemakerUnemployed
If/When employed? What do you do?
Current employer is:
Your Current job:
Total Household income:
Highest degree completed in school:
Please list significant medical problems/conditions, and indicate if you are receiving treatment for them:
Briefly describe any surgeries or hospitalization for serious illness or injuries (What, Where, When, etc.):
If you ever blacked out/ lost consciousness and/or experienced any type of serious head injury or trauma?YesNo
If so, indicate when and what happened?
Do you have a history of the following?
List all medications that you currently use (Please feel free to attach additional sheets as necessary):
Dosage (Amount and time per day)
Name, Address, Phone Number and Fax of Primary Care Physician (PCP):
What was the date of your last complete physical that included labwork?
Please indicate Name, Address, Phone Number and Fax of the doctor who completed the last physical and the results
(Stress, Apt#)(City)(State)(Zip Code)
4. Telephone #Daytime
5. Cell Phone
Patient Name Printed/Date