Name

Email Address

Cell Phone

Home Phone

Address

City

State

Zip

Birthdate

Gender Gender Male Female

What Pronoun do you prefer? he/him, her/she, they/them, other

Occupation

Other Household Members: Names, Ages, and Relationship to you

What issue(s) would you like help in resolving?

Have you seen a therapist for these or any other issues? Have you seen a therapist for these or any other issues? Yes No

If so, when?

Do you have any medical conditions of which I need to be aware?

Have you been given a mental health diagnosis? Have you been given a mental health diagnosis? Yes No

What, if any, medications are you taking?

Are you now, or have you ever been suicidal? If so, when and why?

Do you or anyone in your family have a history of addiction or substance abuse? If yes, please specify.

What would you most like to achieve out of our work together?

Are your parents living? Check if yes. Are your parents living? Check if yes. Mother Father Step-parent

What was your relationship with your parents like growing up? Now?

What is missing in your life to make it ideal?

Emergency Contact (Name, Relationship to you, Phone number):

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