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:
    Email Address:
    Phone:
    Date of Birth:

    What issues are you struggling with?

    What do you hope to get out of therapy?

    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 any mental health diagnoses you have received, if any:

    Please describe any significant addiction you struggle with:

    Check all that apply:
    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.I have not had thoughts of hurting myself or another.

    Please describe any recent thoughts you have had about hurting yourself or someone else:

    Which days and times would work best for your appointments:

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