Please check any of the following issues you may be having at this time. (Check all that apply).
Have you seen a therapist or other practitioner for any of the issues you indicated above (or for any other issues)?
If you answered Yes to the question above, when did you see the therapist or practitioner?
Have you ever been diagnosed with a mental health condition or illness?
What, if any, medications are your currently taking for mental health issues? (If none, please enter "None")
Do you have any medical condition(s) of which I need to be aware?
Are you now, or have you ever been, suicidal?
Do you or anyone in your family have a history of substance abuse?
If you answered Yes to the question above, please provide a brief description.
Please give me a brief description of what you would like help with today.
In a nutshell, please describe for me what your spiritual or religious beliefs are.
Are there any other thoughts/comments you'd like to share with me? (If none, please enter "None" in the box below.)
How did you hear about me?
If referral/other, please specify:
