Name: Street: City/State/Zip: Email: Date of Birth:
Date: Telephone: Cell: Spouse: Occupation:
Has anyone recommended you enter therapy? Who (employer, pastor, lawyer, judge, spouse)? What does this person hope you will accomplish in therapy?
Briefly describe the reason you seek therapy now if different from above:
Please circle any of the following that pertain to you: Nervousness Health problems Legal Matters Self Control Making decisions Inferiority feelings Alcohol Use Marriage Education Stomach trouble Other:__________ Depression Sexual problems Child’s behavior Marital Relationship Insomnia Children Infertility Suicidal thoughts Career choices Separation _____________ Fear Work Anger Stress Energy Sleep Headaches Fatigue Memory Loneliness _________ Shyness Finances Friends Ambition Temper Drug Use Appetite Concentration Nightmares Unhappiness _________________
Please list all members of your family (spouse, children, stepchildren):
Has anyone in your family received therapy before? Please List
What major changes have occurred within your family in the last five years (moves, job change, income change, marriages, birth of children)?
How would you like me help you?
The information contained here is confidential and will be maintained in my file for you if you choose to participate in therapy. _______________________________ Signature ________________________ Date