NAME

DOB

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MAILING ADDRESS (IF DIFFERENT FROM ABOVE):

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CELL PHONE:

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PREFERRED EMAIL ADDRESS: (PLEASE BE AWARE THAT EMAIL IS NOT A SECURE MEANS OF COMMUNICATION) *

PREFERRED METHOD OF CONTACT:

HOW DID YOU HEAR ABOUT THE CLINIC?

RELATIONSHIP STATUS:

SEXUAL ORIENTATION:

RACE/ETHNICITY:

LANGUAGE(S) SPOKEN:

RELIGIOUS OR SPIRITUAL AFFILIATION:

ARE YOU CURRENTLY ACTIVE IN YOUR RELIGION?

YES
NO

PRESENTING PROBLEM

PLEASE STATE BRIEFLY WHAT HAS PROMPTED YOU TO SEEK TREATMENT AT THIS TIME?

HOW LONG HAVE YOU BEEN EXPERIENCING THIS PROBLEM(S)

PLEASE IDENTIFY ANY OF THE BELOW THAT ARE OF CONCERN AT THIS TIME (PLEASE CHECK ALL THAT APPLY):

OUT OF THE ITEMS CHECKED ABOVE, PLEASE LIST YOUR TOP 3 CONCERNS IN ORDER OF IMPORTANCE:

HOW WOULD YOU RATE YOUR CURRENT LEVEL OF DISTRESS REGARDING THE CONCERNS YOU LISTED ABOVE?

PLEASE RATE TO WHAT DEGREE YOUR CONCERN(S) AFFECT YOUR DAY-TO-DAY FUNCTIONING:

	MINIMAL	Disagree	Neutral	Agree	MODERATE	Strongly Agree	Strongly Agree	Strongly Agree	Strongly Agree	SEVERE
Item #1	Item #1 MINIMAL	Item #1 Disagree	Item #1 Neutral	Item #1 Agree	Item #1 MODERATE	Item #1 Strongly Agree	Item #1 Strongly Agree	Item #1 Strongly Agree	Item #1 Strongly Agree	Item #1 SEVERE

EDUCATION & WORK HISTORY

HIGHEST EDUCATION COMPLETED:

WHAT TYPE OF GRADES DID YOU TYPICALLY GET IN SCHOOL?

HAVE YOU BEEN DIAGNOSED WITH A LEARNING DISABILITY?

YES
NO

HAVE YOU BEEN DIAGNOSED WITH A LEARNING DISABILITY? (copy)

YES
NO

ARE YOU CURRENTLY EMPLOYED?

YES
NO

JOB TITLE / DESCRIPTION:

HOW LONG HAVE YOU BEEN AT YOUR CURRENT POSITION?

APPROXIMATELY HOW MANY JOBS HAE YOU HAD IN YOUR ADULT LIFE?

FAMILY HISTORY

WHERE WERE YOU BORN?

WERE YOU ADOPTED?

Yes
No

If yes, do you have any knowledge of your birth family?

WHERE DID YOU GROW UP?

HOW MANY TIMES DID YOU MOVE BEFORE YOU WERE 18 YEARS OLD?

DID YOUR PARENTS DIVORCE OR SEPARATE?

YES
NO

If yes, how old were you at the time?

PLEASE LIST THE (FIRST) NAMES AND AGES OF YOUR IMMEDIATE FAMILY MEMBERS (E.G., PARENTS, SIBLINGS,
CHILDREN, GRANDCHILDREN, GRANDPARENTS, SIGNIFICANT CARETAKERS):

NAME

RELATIONSHIP

AGE

QUALITY OF RELATIONSHIP

4

1

2

3

4

HAS ANYONE IN YOUR IMMEDIATE (PARENTS, SIBLINGS, CHILDREN) OR EXTENDED FAMILY (GRANDPARENTS, COUSINS, ETC.) BEEN DIAGNOSED WITH ANY OF THE FOLLOWING? OR DO YOU SUSPECT THAT THEY MAY HAVE ANY OF THE FOLLOWING?

If you checked any of the above, please elaborate briefly:

MEDICAL HISTORY

DATE OF LAST PHYSICAL EXAM:

RESULTS OF EXAM:

HAVE YOU EVER BEEN HOSPITALIZED FOR A MEDICAL CONDITION?

Yes
No

If yes, please explain:

HAVE YOU EVER SUFFERED A SEVERE HEAD INJURY WITH LOSS OF CONSCIOUSNESS OR CONCUSSION?

Yes
No

If yes, please explain:

DO YOU HAVE CHRONIC PAIN?

Yes
No

If yes, please explain:

PLEASE LIST PAST AND PRESENT MEDICAL CONDITIONS, PROBLEMS AND/OR DIAGNOSES:

PRIMARY CARE PROVIDER (NAME, PHONE, ADDRESS):

PSYCHIATRIST / PSYCHOLOGIST / PSYCHOTHERAPIST (NAME, PHONE, ADDRESS):

PLEASE LIST ALL MEDICATIONS (AND DOSAGE) YOU ARE CURRENTLY TAKING (PLEASE INCLUDE PRESCRIPTION MEDICATION, OVER-THE-COUNTER MEDICATION, VITAMINS, ORAL CONTRACEPTIVES AND ALTERNATIVE REMEDIES):

PLEASE LIST ALL PSYCHOTROPIC MEDICATIONS YOU HAVE TAKEN IN THE PAST, IF ANY (PLEASE INCLUDE DOSAGE, DATES OF USE AND ANY SIDE EFFECTS):

HISTORY OF:

CHECK ONE:

Yes
No

IF YES, PLEASE EXPLAIN BELOW, INCLUDING DATES IF APPROPRIATE:

Seizure disorders

CHECK ONE:

Yes
No

IF YES, PLEASE EXPLAIN BELOW, INCLUDING DATES IF APPROPRIATE:

Respiratory disorders

CHECK ONE: (copy)

Yes
No

IF YES, PLEASE EXPLAIN BELOW, INCLUDING DATES IF APPROPRIATE: (copy)

Respiratory disorders (copy)

CHECK ONE: (copy) (copy)

Yes
No

IF YES, PLEASE EXPLAIN BELOW, INCLUDING DATES IF APPROPRIATE: (copy) (copy)

Respiratory disorders (copy) (copy)

CHECK ONE: (copy) (copy) (copy)

Yes
No

IF YES, PLEASE EXPLAIN BELOW, INCLUDING DATES IF APPROPRIATE: (copy) (copy) (copy)

Respiratory disorders (copy) (copy) (copy)

CHECK ONE: (copy) (copy) (copy) (copy)

Yes
No

IF YES, PLEASE EXPLAIN BELOW, INCLUDING DATES IF APPROPRIATE: (copy) (copy) (copy) (copy)

CHECK ONE: (copy) (copy) (copy) (copy) (copy)

Yes
No

IF YES, PLEASE EXPLAIN BELOW, INCLUDING DATES IF APPROPRIATE: (copy) (copy) (copy) (copy) (copy)

(copy)

CHECK ONE: (copy) (copy) (copy) (copy) (copy) (copy)

Yes
No

IF YES, PLEASE EXPLAIN BELOW, INCLUDING DATES IF APPROPRIATE: (copy) (copy) (copy) (copy) (copy) (copy)

(copy) (copy)

CHECK ONE:

Yes
No

IF YES, PLEASE EXPLAIN BELOW, INCLUDING DATES IF APPROPRIATE: (copy) (copy) (copy) (copy) (copy) (copy) (copy)

(copy) (copy) (copy)

CHECK ONE: (copy)

Yes
No

IF YES, PLEASE EXPLAIN BELOW, INCLUDING DATES IF APPROPRIATE: (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)

(copy) (copy) (copy) (copy)

CHECK ONE: (copy) (copy)

Yes
No

IF YES, PLEASE EXPLAIN BELOW, INCLUDING DATES IF APPROPRIATE: (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)

(copy) (copy) (copy) (copy) (copy)

CHECK ONE: (copy) (copy) (copy)

Yes
No

IF YES, PLEASE EXPLAIN BELOW, INCLUDING DATES IF APPROPRIATE: (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)

(copy) (copy) (copy) (copy) (copy) (copy)

CHECK ONE: (copy) (copy) (copy) (copy)

Yes
No

IF YES, PLEASE EXPLAIN BELOW, INCLUDING DATES IF APPROPRIATE: (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)

(copy) (copy) (copy) (copy) (copy) (copy) (copy)

CHECK ONE: (copy) (copy) (copy) (copy) (copy)

Yes
No

IF YES, PLEASE EXPLAIN BELOW, INCLUDING DATES IF APPROPRIATE: (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)

(copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)

CHECK ONE: (copy) (copy) (copy) (copy) (copy) (copy)

Yes
No

IF YES, PLEASE EXPLAIN BELOW, INCLUDING DATES IF APPROPRIATE: (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)

(copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)

CHECK ONE: (copy) (copy) (copy) (copy) (copy) (copy) (copy)

Yes
No

IF YES, PLEASE EXPLAIN BELOW, INCLUDING DATES IF APPROPRIATE: (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)

(copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)

CHECK ONE: (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)

Yes
No

IF YES, PLEASE EXPLAIN BELOW, INCLUDING DATES IF APPROPRIATE: (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)

(copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)

CHECK ONE: (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)

Yes
No

IF YES, PLEASE EXPLAIN BELOW, INCLUDING DATES IF APPROPRIATE: (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)

(copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)

CHECK ONE: (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)

Yes
No

IF YES, PLEASE EXPLAIN BELOW, INCLUDING DATES IF APPROPRIATE: (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)

(copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)

CHECK ONE: (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)

Yes
No

IF YES, PLEASE EXPLAIN BELOW, INCLUDING DATES IF APPROPRIATE: (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)

(copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)

CHECK ONE: (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)

Yes
No

IF YES, PLEASE EXPLAIN BELOW, INCLUDING DATES IF APPROPRIATE: (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)

(copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)

CHECK ONE: (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)

Yes
No

IF YES, PLEASE EXPLAIN BELOW, INCLUDING DATES IF APPROPRIATE: (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)

(copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)

CHECK ONE: (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)

Yes
No

IF YES, PLEASE EXPLAIN BELOW, INCLUDING DATES IF APPROPRIATE: (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)

(copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)

CHECK ONE: (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)

Yes
No

IF YES, PLEASE EXPLAIN BELOW, INCLUDING DATES IF APPROPRIATE: (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)

(copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)

CHECK ONE: (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)

Yes
No

IF YES, PLEASE EXPLAIN BELOW, INCLUDING DATES IF APPROPRIATE: (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)

(copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)

CHECK ONE: (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)

Yes
No

IF YES, PLEASE EXPLAIN BELOW, INCLUDING DATES IF APPROPRIATE: (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)

(copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)

CHECK ONE: (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)

Yes
No

IF YES, PLEASE EXPLAIN BELOW, INCLUDING DATES IF APPROPRIATE: (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)

(copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)

CHECK ONE: (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)

Yes
No

IF YES, PLEASE EXPLAIN BELOW, INCLUDING DATES IF APPROPRIATE: (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)

CHECK ONE: (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)

Yes
No

IF YES, PLEASE EXPLAIN BELOW, INCLUDING DATES IF APPROPRIATE: (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)

MEDICAL HISTORY CONTINUED

WERE THERE ANY COMPLICATIONS AT YOUR BIRTH? (E.G., PREMATURE BIRTH, MEDICAL PROBLEMS)

Yes
No

If yes, please explain:

DID YOU EXPERIENCE ANY PROBLEMS IN YOUR EARLY DEVELOPMENT (E.G., LEARNING TO WALK, TALK, ETC.)?

Yes
No

If yes, please explain:

-FOR FEMALE PATIENTS

AGE OF FIRST PERIOD:

HOW MANY TOTAL PREGNANCIES HAVE YOU HAD?

HOW MANY TOTAL PREGNANCIES HAVE YOU CARRIED TO TERM?

WHICH BEST DESCRIBES YOUR MENSTRUAL CYCLE NOW?

RELATIONSHIP HISTORY

AGE AT FIRST SIGNIFICANT ROMANTIC RELATIONSHIP:

TOTAL NUMBER OF MARRIAGES / LONG TERM (OVER 1 YEAR) RELATIONSHIPS:

IF YOU ARE MARRIED / PARTNERED, PLEASE BRIEFLY DESCRIBE YOUR RELATIONSHIP:

IF YOU ARE CURRENLTY SINGLE, DIVORCED, SEPARATED OR WIDOWED, PLEASE BRIEFLY DESCRIBE YOUR LAST LONG TERM RELATIONSHIP:

MENTAL HEALTH HISTORY

HAVE YOU EVER SOUGHT MENTAL HEALTH TREATMENT?

Yes
No

If yes, please complete the following about your past (or present) treatment experience(s)

Provider Name

PROVIDER CONTACT INFO:

APPROXIMATE DATES:

PROBLEM(S) ADDRESSED?

WAS TREATMENT HELPFUL?

Provider Name

PROVIDER CONTACT INFO:

APPROXIMATE DATES:

PROBLEM(S) ADDRESSED?

WAS TREATMENT HELPFUL?

HAVE YOU EVER BEEN HOSPITALIZED FOR A PSYCHIATRIC CONDITION?

Yes
No

If yes, please describe the circumstances of your hospitalization (how long, name of facility, dates):

HAVE YOU EVER BEEN ADMITTED TO RESIDENTIAL OR INTENSIVE OUTPATIENT TREATMENT?

Yes
No

If yes, please describe the circumstances of your treatment (how long, name of facility, dates):

DO YOU USE TOBACCO?

Yes
No

HAVE YOU USED ANY DRUGS IN THE PAST 30 DAYS THAT WERE NOT PRESCRIBED BY A HEALTHCARE PROFESSIONAL (E.G., MARIJUANA, HASH, COCAINE, ADDERALL, DIET PILLS, ECSTASY, VALIUM, LSD, ACID, MUSHROOMS, HEROIN, VICODIN, CODEINE, OR OTHER)?

Yes
No

If yes, please describe (including the amount and frequency):

HAS ANYONE EVER SUGGESTED YOU DRINK ALCOHOL OR USE DRUGS TO EXCESS?

Yes
No

HAVE YOU EVER BEEN IN TREATMENT FOR SUBSTANCE AND/OR ALCOHOL USE?

Yes
No

If yes, please describe the circumstances of your treatment (how long, name of facility, dates):

DO YOU FEEL YOUR TECHNOLOGY USE IS BALANCED?

Yes
No

DO YOU EVER HAVE PROBLEMS CONTROLLING THE AMOUNT OF FOOD YOU EAT?

Yes
No

HAVE YOU EVER HAD THOUGHTS OF HARMING YOURSELF?

Yes
No

HAVE YOU EVER PURPOSELY INJURED YOURSELF WITHOUT SUICIDAL INTENT (E.G., CUTTING, HITTING, BURNING)?

Yes
No

IN THE PAST FEW WEEKS, HAVE YOU HAD THOUGHTS OF SUICIDE?

Yes
No

If yes, please describe the types of thoughts (including frequency, intensity and duration) and whether you have acted on these thoughts:

HAVE YOU SERIOUSLY CONSIDERED SUICIDE IN THE PAST?

Yes
No

If yes, please describe

HAVE YOU EVER SERIOUSLY CONSIDERED HARMING ANOTHER PERSON?

Yes
No

If yes, please describe:

HAVE YOU EVER INTENTIONALLY PHYSICALLY HARMED ANOTHER PERSON?

Yes
No

If yes, please describe:

DO YOU CURRENTLY HAVE THOUGHTS OF HARMING ANOTHER PERSON?

Yes
No

If yes, please describe:

HAS ANYONE IN YOUR FAMILY ATTEMPTED OR COMMITTED SUICIDE?

Yes
No

If yes, please describe:

If yes, please describe the types of thoughts (including frequency, intensity and duration):

DO YOU CURRENTLY HAVE ACCESS TO ANY WEAPONS, INCLUDING FIREARMS?

Yes
No

If yes, please describe:

HAVE YOU EVER BEEN ARRESTED OR CONVICTED OF A CRIME?

Yes
No

If yes, please describe (including when):

ARE YOU PRESENTLY INVOLVED IN A LAWSUIT?

Yes
No

If yes, please describe

ARE YOU SEEKING TREATMENT DUE TO AN ACCIDENT OR INJURY?

Yes
No

If yes, please describe

ARE YOU REQUIRED BY A COURT, THE POLICE OR A PROBATION/PAROLE OFFICER TO BE IN TREATMENT?

Yes
No

If yes, please indicate the amount and frequency:

HOW MANY BEVERAGES CONTAINING ALCOHOL DO YOU CONSUME IN A TYPICAL WEEK?

HOW MANY BEVERAGES CONTAINING CAFFEINE DO YOU CONSUME IN A TYPICAL DAY?

APPROXIMATELY HOW MANY HOURS PER DAY DO YOU SPEND ONLINE?

SOCIAL NETWORKING SITES

YOUTUBE

GAMING

BROWSING

SHOPPING

GAMBLING

PORNOGRAPHY SITES

OTHER

HOW MANY TIMES PER YEAR DO YOU GAMBLE (ONLINE OR OTHER)?

If yes, please describe the types of behavior(s) (including frequency, intensity and duration):

WHAT GIVES YOU THE MOST PLEASURE IN YOUR LIFE?

WHAT ARE YOUR MAIN WORRIES OR FEARS?

WHAT ARE YOUR MOST IMPORTANT HOPES AND DREAMS

IS THERE ANYTING ELSE YOU WOULD LIKE YOUR HEALTHCARE PROFESSIONAL TO KNOW?

LEGAL HISTORY

REFLECTIONS

OTHER

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