Name
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First Name
Last Name
Gender and Age
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Birth Date and Place
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Street Address (you may receive mail from me here), including unit number if applicable
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City, State, Zip
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Preferred Contact
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Contact Information
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If I may leave confidential messages for you, where may they be left?
Notes for where confidential messages may be left:
The person I should call in case of emergency, their relationship to you, and their phone number:
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Alternative person, relationship, and phone number to call in case of emergency:
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Referral source:
Please write in days and times you are most likely to be available for therapy:
Please describe the issues or concerns which caused you to seek therapy:
On a scale of 0-10, with 0 meaning no distress, and 10 meaning the most distress you can imagine, rate the severity of the issues or concerns you described above:
What do you hope to get from therapy?
Describe any particular concerns or fears you may have with regard to therapy:
List the life stressors, current or past, which have effected your thoughts or feelings:
On a scale of 0-10, with 0 meaning no stress, and 10 meaning the most stress you can imagine, rate the severity of the life stressors you described above:
Education:
Occupation (please include former chief occupations):
On a scale of 0-10, with 0 meaning total dissatisfaction, and 10 meaning the greatest possible satisfaction, rate how satisfied you are with your current employment situation:
Is there pending or are you now or have you ever been involved in civil or criminal litigation, lawsuits or divorce and custody disputes?
If so, please describe:
Describe the purpose of any previous counseling, therapy, or mental health treatment of any kind:
Describe what was most and least helpful about it:
When and for how long?
Please list the names of treating professional(s), if remembered:
Have you ever received a mental health diagnosis?
If so, please list the diagnosis or diagnoses here, and describe the related circumstances:
Have you ever been hospitalized for mental health?
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If so, where, when, and for how long?
Do you have any physical symptoms associated with your mental or emotional health?
If so, please describe:
Have you ever taken any medications related to your emotional or mental well-being?
Please list dosages, frequencies, and for how long:
Do you take other prescription or over-the-counter medications?
Please list dosages, frequencies, and for how long:
Do you currently use illegal drugs?
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If so, please describe:
Have you ever used drugs in a substantial way?
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If so, please describe:
Over the last two weeks, on how many occasions have you had three or more drinks in one sitting?
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Have you ever been in a 12-step program?
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If so, please describe:
Have you ever attempted suicide?
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If so, please describe when and related to which circumstances:
Have you had any thoughts of suicide in the last three months?
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On a scale of 0-10, where 0 is no thoughts of suicide, and 10 is the thought that suicide is inevitable, where has it been at its worst over the last three months?
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Please describe how many times over the last three months it has been at its worst:
On that same scale of 0-10, where 0 is no thoughts of suicide, and 10 would be about to commit suicide, what number is closest to matching what you have felt most recently?
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Have you ever hurt yourself intentionally by cutting or other means?
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If so, please describe when and how:
Do you have thoughts of hurting others?
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If so, please describe:
Describe the worst time of your adult life:
Describe the best time of your adult life:
Have you ever been the victim of a violent crime?
If so, please describe:
Have you ever been convicted of a serious crime?
If so, please describe:
Your preference for a male or female therapist:
Briefly describe your childhood:
Describe the worst time in your childhood:
Describe the best time in your childhood:
Who held and comforted you as a child?
Were you subjected to verbal, physical, emotional, or sexual abuse?
If so, please describe:
List family members who have abused alcohol or drugs:
Describe any history of illnesses in the family. Please include any instances of mental illness, violence, or suicide:
Name of your spouse or partner:
Year married or partnered:
From 0 to 10, with 10 being high, rate the degree to which you feel your partner currently cares about you:
Spouse or partner’s education:
Spouse or partner’s occupation (please include former chief occupations):
Names of former spouses or partners, and the dates, from beginning to end, you were married or partnered for each:
Describe the nature of the relationship(s) at the time you were in them, e.g., friendly, distant, physically or emotionally abusive, loving, hostile — anything that helps describe what it was like:
Names and ages of children you have parenting responsibilities for, and a brief description of your relationship with each:
Describe each child’s relationship with each person who has parenting responsibilities in their lives:
Please describe your spiritual identity or orientation:
How would you describe your social support system?
What gives you most joy or pleasure in your life?
What are your main worries and fears?
What would you say are your most important hopes or dreams?
Please include any other information you feel is relevant to your therapy:
By entering my name below, I affirm my belief that the above statements are true, to the best of my knowledge:
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Date
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