Please submit this form prior to our first appointment. Providing this information will accelerate the process of our work and will also help us to identify areas of your life that need special attention. Please leave blank any questions you would rather not answer. Information you provide here is held to the same standards of confidentiality as our therapy.
Name
First Name
Last Name
Gender, Pronoun/s, Age, and Date of Birth
Marital/Partnership Status
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email
Phone
(###)
###
####
How do you prefer to be contacted?
Presenting challenges that have brought you to therapy:
Duration of challenges:
Events that led to your seeking help:
Recent life changes or stressors:
Intentions/goals for therapy:
What do you know (if anything) about your birth?
Did you nurse? How long?
What is your earliest significant memory?
How would you describe your childhood/middle-school/adolescent years?
Tell me about the family system in which you were raised (e.g. with parents, married or divorced, sblings, extended family, etc.).
How would you describe the family environment in which you grew up? (e.g. peaceful, loving supportive, hostile, chaotic, violent, etc.)
Please list any current or past medical conditions:
Please list any current medications:
Please describe any history of head injuries:
Do you currently use alcohol or drugs? If so how much, how often, and how long have you used these substances? Have you ever been in treatment for substance abuse?
Do you have any history of complusive behaviors, such as sexual addiction, gambling, shopping, exercise addiction, over-eating, etc? If so, please explain:
Are there any medical conditions/concerns that you have which would be helpful for me to know about? Please explain.
At what age did you begin school?
Did you enjoy school? Why or why not?
What were/are your favorite subjects?
Was there anything 'atypical' in your educational experience, e.g., were you in gifted or talented classes, or were you diagnosed with a learning disability?
Are you currently employed? If so, how do you feel about your current position?
Please list any work-related stressors, if any:
Do you prefer job tasks where you work individually, or with groups?
Were you raised with a religious/spiritual orientation? If so, please describe:
Do you consider yourself to be a spiritual/religious person? If yes, what is/are your faith(s)?
Do you have a consistent spiritual practice and if so, please share:
What role (if any) does spirituality or religion play in your life?
To whom were you closest as a child?
Did you have a mentor or mentors as a child (e.g. parent, teacher, coach, friend's parent, etc.?):
Were you shy or outgoing as a child? How are you as an adult?
Please describe your current friendships (anything you say here is fine):
How do you feel about the quality of your friendships?
Are you happy with the size of your current network of friends and acquaintances?
How do you typically meet friends?
Have you experienced any significant losses (e.g. death of a loved one?)
Are you currently in a romantic relationship? If so, how long have you been in this relationship?
On a scale of 1-10, how would you rate the quality of your current relationship?
Please list previous significant relationships and durations:
How do you typically meet your romantic partners?
I have experienced:
Please expand on any of the above checked boxes with your age at the time of occurence and anything else you want to say:
Please check any of the following that apply to your family (immediate or relatives):
Please expand on any of the checked areas above with family member and anything else you want to say:
Please check any of the following that YOU have experienced:
Have you ever been in counseling? If so, when and for how long?
If so, what brought you to counseling at that time?
If so, how was your experience(s) with counseling? What worked? What did not work?
Have you ever experienced art therapy?
What are your feelings about making art?
Are you interested in exploring your challenges through art and other creative processes?
What do you consider to be your strengths?
What do you like most about yourself?
What are effective coping strategies that you've learned?
What do you do for fun and self-care?
What else might be helpful for me to know about you?
If you will be using your insurance to help with the cost of counseling, please complete the following. You may find out this information by calling the number listed on the back of your insurance card (or online if your insurance carrier has online benefit information).
Insurance Company:
Insurance ID number and Group number:
If your mental health counseling benefits are subject to a deductible, what is your deductible and how much of that deductible have you met?
What is your co-pay and/or co-insurance for each counseling appointment?