First Name |
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Last Name |
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Middle Initial |
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Birth Date |
(MM/DD/YYYY)
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Age |
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Social Security Number |
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Gender |
Male
Female
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Address Line 1 |
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Address Line 2 |
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City |
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State |
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Zip |
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Home Phone |
May we leave a message?
Yes
No
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Mobile Phone / Other |
May we leave a message?
Yes
No
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Email |
May we email you?
Yes
No
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Please note: Email correspondence is not considered to be a confidential medium of communication and will be utilized in rare cases only. |
Marital Status |
Never Married
Domestic Partnership
Married
Separated
Divorced
Widowed
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Children |
If Applicable (list first names and ages below) |
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Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc.)?
Yes
No
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If yes, who was your previous therapist/practitioner?
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Why did you stop treatment? (please explain) |
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Are you currently taking any prescription medication?
Yes
No
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If yes, please list medications below: |
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Have you ever been prescribed psychiatric medication?
Yes
No
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If yes, please list medications and dates below: |
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FAMILY MENTAL HEALTH HISTORY: |
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In the section below, identify if there is a family history of any of the following. If yes, please indicate the family member’s relationship to you in the space provided (father, grandmother, uncle, etc.). |
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Alcohol
Yes
No
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Anxiety
Yes
No
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Depression
Yes
No
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Domestic Violence
Yes
No
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Eating Disorders
Yes
No
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Obesity
Yes
No
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Obsessive Compulsive Behavior
Yes
No
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Bipolar Disorder
Yes
No
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Suicide Attempts
Yes
No
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GENERAL HEALTH AND MENTAL HEALTH INFORMATION: |
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How would you rate your current physical health? |
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Poor
Unsatisfactory
Satisfactory
Good
Very Good
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Please list any specific health problems you are currently experiencing: |
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How would you rate your current sleeping habits? |
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Poor
Unsatisfactory
Satisfactory
Good
Very Good
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Please list any specific sleep problems you are currently experiencing: |
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Please list any difficulties you experience with your appetite or eating patterns: |
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Are you currently experiencing overwhelming sadness, grief, or depression?
Yes
No
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If yes, for approximately how long?
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Are you currently experiencing anxiety, panic attacks, or have any phobias?
Yes
No
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If yes, when did you begin experiencing this? |
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Are you currently experiencing any chronic pain?
Yes
No
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If yes, please describe: |
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Do you drink alcohol more than once a week?
Yes
No
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Type:
Frequency:
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How often do you engage recreational drug use? |
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Daily
Weekly
Monthly
Infrequently
Never
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ADDITIONAL INFORMATION: |
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Are you currently employed?
Yes
No
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If yes, what is your current employment situation? |
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Do you enjoy your work? Is there anything stressful about your current work? |
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If you are a student what school do you attend? What grade/year? |
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Extracurricular activities (if any): |
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Do you consider yourself to be spiritual or religious?
Yes
No
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If yes, please describe your faith or belief: |
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What do you consider to be some of your strengths? |
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What do you consider to be some of your weaknesses? |
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Why have you sought therapy treatment at this time? |
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What would you like to accomplish out of your time in therapy? |
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What else do you feel I should know about you to best help you as your therapist? |
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INSURANCE INFORMATION |
Insurance Company Name |
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Insurance Company Phone |
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ID# |
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Group # |
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Policy Holder Information
Please check this box if the client and the policy holder are the same,
otherwise please complete the policy holder information below. |
First Name |
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Last Name |
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Address Line 1 |
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Address Line 2 |
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City |
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State |
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Zip |
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Phone |
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Employer |
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Social Security Number |
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Birth Date |
(MM/DD/YYYY)
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Gender |
Male
Female
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Client's Relationship to
Policy Holder |
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