Please take your time in providing the following information. The questions are designed to help me begin to understand you so that our time together can be as productive as possible. All information provided is confidential.
Referred by
Psychology Today
My Website:
Have you previously received any type of mental health services?
If yes, which of the following:
If yes, please provide:
Briefly, what brings you in today
When did your problem first start? Within the last:
What areas of your life have been affected because of this problem?
Are you currently experiencing overwhelming sadness, grief or depression?
Are you currently experiencing anxiety, panic attacks or have any phobias?
Family History
Please list your parents and siblings. Please use additional space on the back if needed
Where do they live now?
If deceased, age and cause of death
Please circle
List Family Member
Marital Status:

Are you currently in a romantic relationship?

Please list any children, their names, and ages:
Name of other parent
If deceased, age and cause of death

Physical Health

Please list any medications, herbs, or supplements. Be sure to include the condition, as some medications are prescribed for offlabel use. Continue on the back if needed, or provide a separate list. If you have a complicated medical profile, please supply supporting documentation to be able to facilitate a comprehensive understanding of your health.

Date Began/Stopped

Prescribing provider and contact information:

How would you rate your current physical health?

Please list any specific health problems you are currently experiencing:

How would you rate your current sleeping habits?

Please list any other specific sleep problems you are currently experiencing:

Are you currently experiencing any chronic pain?

Additional Information