Clinical Forms

First Name

Middle Initial

Last Name

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Phone

Email

Other Phone

Birthday

May I leave a message? (Not confidential)

Yes

No

May I email You? (Not confidential)

Yes

No

May I leave a message?

Yes

No

Sex

Contact Name

Contact Phone

SPOUSAL/PARTNER INFORMATION

Spouse/Partners First Name

Middle Initial:

Last Name:

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Phone

Partner Birthdate

May I leave a message? (Not confidential)

Yes

No

Partner Sex

EMPLOYMENT INFORMATION:

Company

Company’s Address

Company’s Phone:

Do you enjoy your work?

Yes

No

Are there any unusual stressors with your current work?

Yes

No

If Yes, List

INSURANCE INFORMATION:

Insurance Company Name

Insurance Phone

Insurance Company Address:

Policyholder

Policyholders date of birth:

Policy Number

Applicant’s relationship to policy holder:

Self

Spouse

Child

Other

Group Number:

Co-Pay Amount:

PAYMENT FOR SERVICE: All insurance Co-payments are due at the beginning of each therapy session. Payments can be made in the form of Cash, Check, Visa, MasterCard, HSA and Discover.

Thank you.

SPIRITUALITY/ RELIGION:

Actively Involved Member?

Yes

No

Explain

Do you consider yourself to be religious or spiritual?

Yes

No

Spiritual Practices?

Thanks for submitting! Please continue with Counseling history form.

Full Name

COUNSELING HISTORY:

What would you like to accomplish out of your time in therapy?

Previous mental health services (psychotherapy, psychiatric services, etc.)?

Yes

No

If yes, please list the previous therapist/practitioner:

Have you ever been prescribed psychotropic medication (e.g. for depression, anxiety, etc.?)

Yes

No

If yes, Please list & provide dates:

Suicidal thoughts, if so how often?

Everyday

Weekly

Other

Thoughts of harming others, if so how often?

Everyday

Weekly

Other

Adult/Child Abuse

Mental

Physical

Sexual

Emotional

GENERAL HEALTH & MENTAL HEALTH INFORMATION:

Primary Physicians:

Clinic:

Address:

Phone

Last date seen

Current Diagnosis

List of medications

Please list any specific health problems you are currently experiencing

Please list any specific sleep problems you are currently experiencing

What types of exercise to you participate in

How many times per week do you generally exercise?

1-2X

3-4X

5-7X

Do you engage recreational drug use?

Yes

No

Never Have

If yes, how often:

Daily

Weekly

Monthly

Occasionally

Are you currently in a romantic relationship?

Yes

No

If yes, for how long?

Are there any recent significant life changes or stressful events? If so list:

Were there any significant traumatic past or current events in your life? If so list:

FAMILY MENTAL HEALTH HISTORY:

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.

Thanks for submitting! Please continue with ADDITIONAL INFORMATION Form

SPOUSAL/PARTNER INFORMATION

EMPLOYMENT INFORMATION:

INSURANCE INFORMATION:

SPIRITUALITY/ RELIGION:

COUNSELING HISTORY:

GENERAL HEALTH & MENTAL HEALTH INFORMATION:

FAMILY MENTAL HEALTH HISTORY:

ADDITIONAL INFORMATION: