All fields are required. Write N/A for "not-applicable".

    Who is your clinician?
    Client Full Legal Name:

    Name of Person Filling Out Form: SameOther:

    What issues are you struggling with?

    What have you tried so far?

    What do you hope to get out of therapy?

    Describe Current Medical Concerns:

    Describe Previous Medical Concerns, Illnesses, Hospitalizations:

    List all Current Medications and Supplements (over-the-counter & prescription):

    Prior Mental Health Treatment:
    I have seen a mental health professional before. (psychiatrist, psychologist, counselor, etc.)I am currently seeing a mental health professional. (psychiatrist, psychologist, counselor, etc.)I have been admitted to a hospital for mental health issues.I have never seen a mental health professional before.

    Please list all mental health professionals, why you saw them, and dates of treatment:

    What is your current relationship status? (Check all that apply.)
    Single - Not DatingSingle - Dating AroundSingle - Committed RelationshipMarriedDivorcedWidowedEngagedLive-in Partner

    Current Partner's Name (or "none"):
    Significant Previous Partners*: (names and relationship dates)

    Children (name, age, adopted, step):

    Do you identify with any religion or spirituality?

    Tell me about your educational background and hopes for the future (if any):

    Tell me about your employment background and hopes for the future (if any):

    Describe any family history of mental illness (depression, anxiety, bipolar, etc.) and if they have been helped by medication:

    Describe any family history of substance abuse or alcoholism:

    Current Substance Use:
    How much alcohol do you drink? (Type, amount, frequency)
    How much tobacco do you use? (Type, amount, frequency)
    How much caffeine do you use? (Type, amount, frequency)
    How much cannabis, THC, or oil do you use? (Type, amount, frequency)
    How many prescription pain killers do you use? (Type, amount, frequency)
    Do you use any other recreational drugs? (Type, amount, frequency)
    Describe any struggles with sugar or carb consumption?
    Describe any struggles with screens or technology?
    Do you struggle with pornography?
    Any other possible addictions or compulsions?

    Describe any significant history around your addictions or compulsions:

    Typical times for going to sleep and waking up:

    Sleep: Check all that apply:
    Difficulty Falling AsleepDifficulty Getting out of BedFrequent Nighttime WakingTypically Feel Well-RestedTypically Feel TiredFrequent NightmaresExcessive Daytime NappingFalling Asleep in Dangerous Situations

    Check all that apply:
    I would like to feel better about myself.I get angry easily.I am uncomfortable in most social situations.I often push away the people closest to me.People talk about me a lot.Sometimes I drink too much.I have difficulty finishing tasks or projects.I frequently have racing thoughts.In the past, I have had thoughts of hurting myself.I have recently had thoughts of hurting myself.I have recently had thoughts of hurting someone else.

    On a scale 1-10, how stressed are you? (10=most stressed)
    What are you most stressed about?

    On a scale 1-10, how happy are you? (10=most happy)
    What makes you most happy?

    What else would be helpful for me to know about you?