Make Stress A Thing Of The Past
Please provide the following information and answer the questions below. Please note: Information you provide her is protected as confidential information.
Name of parent/guardian (if under 18 years):*
Never MarriedDomestic PartnershipMarriedSeparatedDivorcedWidowed
List any children/age*
United StatesIndiaIndonesiaCote D'ivoireIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyan Arab JamahiriyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States)MoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandKorea (Democratic People's Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestinian Occupied TerritoriesPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarKosovo, Republic ofReunionRomaniaRussian FederationRwandaSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and The GrenadinesSamoaTaiwan; Republic of China (ROC)TajikistanThailandTimor-LesteTogoTokelauUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVenezuelaVietnamWallis and Futuna IslandsWestern SaharaYemenZambiaZimbabwe
Referred By (if any):*
1. What are your current concerns?
2. What are you hoping to accomplish from counseling?
Have you previously recieved any type of mental health services (psychotherapy, psychiatric services, etc.)?*
If so list previous Therapist/Practitioner*
Are you currently taking any prescription medication?*
If so list any prescription medications*
Have you ever been prescribed psychiatric medication?*
GENERAL HEALTH INFORMATION
1. How would you rate your current physical health? (select one)*
List any specific health problems you are currently experiencing:*
2. How would you rate your current sleeping habits? (select one)*
Please list any specific sleep problems you are currently experiencing:*
3. How many times per week do you generally exercise?*
What types of exercise do you participate in?*
4. Please list any difficulties you experience with your appetite or eating patterns:*
5. Are you currently experiencing overwhelming sadness, grief or depression?*
If yes, for approximately how long?*