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Clinical Forms

Please be sure to check all the tabs and fill all the forms

For your convenience, you can download and print the following forms.

May I leave a message? (Not confidential)
May I email You? (Not confidential)
May I leave a message?
Marital/Partnership Status
Contact in Case of Emergency
SPOUSAL/PARTNER INFORMATION
May I leave a message? (Not confidential)
EMPLOYMENT INFORMATION:
Do you enjoy your work?
Are there any unusual stressors with your current work?
INSURANCE INFORMATION:
Applicant’s relationship to policy holder:

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:
Religious Affiliation, if any
Actively Involved Member?
Do you consider yourself to be religious or spiritual?

Thanks for submitting! Please continue with Counseling history form.

COUNSELING HISTORY:
Previous mental health services (psychotherapy, psychiatric services, etc.)?
Have you ever been prescribed psychotropic medication (e.g. for depression, anxiety, etc.?)
Check the main reason(s) you have decided to seek counseling at this time?
Suicidal thoughts, if so how often?
Thoughts of harming others, if so how often?
Adult/Child Abuse
Relationship Issues
GENERAL HEALTH & MENTAL HEALTH INFORMATION:
How would you rate your current physical health?
PoorFairSatisfactoryGoodVery Good
How would you rate your current sleeping habits?
PoorFairSatisfactoryGoodVery Good
Please list your experience with appetite or eating patterns.
Picky eaterRoutine EaterBinge Eater
Do you drink alcohol?
How many times per week do you generally exercise?
Do you engage recreational drug use?
If yes, how often:
Are you currently in a romantic relationship?
How would you rate that relationship?
PoorFairGoodVery goodExcellent
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.

If Married/Cohabitating: Please rate the quality of your immediate family relationships:
PoorFairSatisfactoryGoodVery Good
Please rate the quality of your family of origin relationships:
PoorFairSatisfactoryGoodVery Good
Alcohol/Substance Abuse:
Anxiety
ADHD (Inattentive/Impulsive:
Depression:
Domestic Violence:
Obesity:
Schizophrenia:
Eating Disorders:
Obsessive Compulsive Behavior
Depression & Suicide Attempts:

Thanks for submitting! Please continue with ADDITIONAL INFORMATION Form

ADDITIONAL INFORMATION:
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