Date:

MM

DD

YYYY

Name *

First Name

Last Name

Date of Birth: *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Primary Phone Number

Only leave a phone number if we are able to leave a message.

(###)

###

####

Secondary Phone Number

Only leave a phone number if we are able to leave a message.

(###)

###

####

Name of Guardian

First Name

Last Name

Address of Guardian

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Guardian's Primary Phone Number

Only leave a phone number if we are able to leave a message.

(###)

###

####

Guardian's Secondary Phone Number

Only leave a phone number if we are able to leave a message.

(###)

###

####

Emergency Contact Name

First Name

Last Name

Emergency Contact Phone Number

(###)

###

####

Check all words/phrases that describe what you are experiencing.

Depression/sad/down

High/low energy level

Angry/irritable

Loss of interest in activities

Difficulty enjoying things

Crying spells

Decreased motivation

Withdrawing from people

Mood Swings

Change in weight or appetite

Suicidal thoughts or plans

Poor concentration

Feelings of hopelessness

Feelings of shame or guilt

Feelings of being cheated

Feelings of inadequacy

Anxious/nervous/tense

Panic attacks

Racing or scrambled thoughts

Bad or unwanted thoughts

Flashbacks

Muscle tensions, aches, ets.

Hearing voices

Seeing things

Thoughts of hurting people

Thoughts of running away

People are out to get me hurt or hurt me

Feelings of frustration

Indecisiveness about career

Job Problems

Other

Have you received or participated in previous counseling and/or therapy?

Yes

No

Have you had hospital stays for psychological concerns?

Yes

No

Are your currently experiencing thoughts of harming either yourself or someone else?

Yes

No

Have you in the past experienced thoughts of harming either yourself or someone else?

Yes

No

Are you aware of any difficulties or complications during the time your mother was pregnant with you?

Yes

No

Did you walk, talk, and read on time?

Yes

No

How would you rate your current physical health

Excellent

Very Good

Good

Fair

Poor

Very Poor

What was the date of your last physical or routine health "check up?"

MM

DD

YYYY

Raised by

Mother

Father

Step-Mother

Step-Father

Other

When attending school were you

In regular classes

Home study

Special classes

Ever suspended

Marital status date

MM

DD

YYYY

Name *

First Name

Last Name

Date *

MM

DD

YYYY