At the end of this page you can print out a PDF copy of this form to fill out and return to me at your first appointment.
Name_____________________________________ Birth Date _____________ Age________
Telephones: Home_______________ Work________________ Cell_____________________
Is it OK to leave a message? Yes No Or text your cell? Yes No
e-mail___________________________ Is it OK to use this email? Yes No
How did you hear about my services or me? __________________________________________
Please list people currently living with you and their relationship to you:
City_______________________________ State__________ Zip__________________
Marital or long-term committed relationship status _____________________________________
Contact in case of emergency: Name ________________________________________________
I would like to receive by email future newsletters or information about upcoming events: yes no
Email address to use:
Describe the problem with which you would like assistance.
What has been done about this problem/issue in the past and with what results?
How is your life satisfying? How isn’t it satisfying? What needs to change for your life to be fully satisfying?
Describe your present social activities. Describe your social support system. Is it meeting your needs?
How do you feel about your present job/life role? Describe your work/life role history.
Do you have a spiritual connection? Describe your relationship with spirituality/religion/faith.
Are there any current legal issues? If so, what?
Health & Medical Information
Describe your medical history–any illnesses, injuries or operations you have had:
Illness Dates Comments
Describe your general health and how you feel about your health.
Describe any current or recent body problems. If being treated, what is the treatment, the name and phone # of the practitioner?
Do you believe in your ability to heal? How do you feel about your body?
Have you consulted a mental health professional in the past? If yes, who, when, where, why and with what results?
What prescription or OTC medications are you currently using? For what purpose?
Describe your present eating habits.
Describe frequency and amounts of any recreational drug/alcohol use in the last 18 mos. What, when, how often, how much (be specific).
Describe any addictions including drugs/alcohol, food, cigarettes, behaviors (gambling, sex, spending or other).
Are there any events from the past that continue to cause emotional distress?
Relationships and Family
Do you have a current or recent primary relationship? Describe the quality.
Briefly describe the important relationships in your past and how they impacted you.
Do you have children? List names, ages, and gender. How do you relate to each?
Describe your parents’ relationship to each other past and present. Or that of any other major care givers.
Describe your parents’ (or other caregiver’s) relationship to you past and present.
What did you like about each parent when you were growing up?
What did you not like about each parent?
Briefly describe your infancy and childhood.
Siblings: list names, ages, gender in birth order. Describe your present and past relationship with each.
Print out the PDF of the CONFIDENTIAL INFORMATION QUESTIONNAIRE fill it out and bring it to your appointment.