Name
*
First Name
Last Name
Date of Birth
Age
Gender
Individual Concerns
Marital Status
Length of current relationship
Assessment of current relationship
How many times have you been married?
Current household & family information
For everyone in your family, please list the name, relationship, age, gender, type (bio/step, etc), & are they living with you
Currently enrolled in high school/GED?
Yes
No
College?
Yes
No
Vocational School?
Yes
No
Graduate School?
Yes
No
List any other training
Any special circumstances regarding education?
Military Experience
Yes
No
Combat experience
Yes
No
Where
Branch
Length of service
Type of discharge
Rank at discharge
If yes, where
Approximate dates of counseling
For what reason did you go to counseling
Do you have a previous mental health diagnosis?
What did you find most helpful in counseling?
What did you find least helpful in counseling?
Have you used psychiatric services
If yes, was it helpful
Please list any other medical concerns
Chemical Use & History
Do you currently use alcohol?
If yes, how often do you drink
How much do you drink
Do you currently use tobacco
If yes, how much do you smoke/chew
Do you currently use any other drugs
If yes, what drugs do you use
If yes, how often do you use
Have you received any previous treatment for chemical use
If so, was it inpatient or outpatient
N/A
Inpatient
Outpatient
Where was the treatment
Current Reason For Seeking Counseling
Briefly describe the problem for which you are seeking to have counseling?
When did these symptoms first occur
What would you like to see happen as a result of counseling
What is most concerning right now
Family History
What word would you use to describe your family of origin
Are you aware of any birth trauma your mom had during her pregnancy with you, or from age 0-3 years
Did you experience any abuse as a child inside or outside your home (physical, verbal, emotional, or sexual)? Please describe as much as you feel comfortable.
Have you experienced any abuse in your adult life (physical, verbal, emotional, or sexual)?
Please check any family concerns that your family is currently experiencing
Describe any other concerns not listed above
Individual Concerns
Check items that are of moderate to severe concerns
Other concerns not listed above
Address
*
City
*
State
*
Zip Code
*
Email
*
Phone
*
(###)
###
####
