Request for Appointment

First name *
Last name *
Email *
Address *
City *
State *
Zip code *
Phone *
Birthday *
Gender
Other Male Female

Do you have insurance?
No Yes

What type of services would you like to receive? *

• Therapy
• Certified Coaching
• Marriage Counseling
• Substance Abuse

What is your ID Number?

Please choose your current educational status? Other Freshman Sophomore Junior Senior College

Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc.)

Have you ever been diagnosed with a psychiatric condition?

Have you had any Psychiatric hospitalizations?

Are you currently taking any prescription medication?

Have you ever been prescribed psychiatric medication?

How would you rate your current physical health? *

• Poor physical health
• Fair physical health
• Good physical health

Please list any specific health problems you are currently experiencing:

Family Practitioner’s Name:

How would you rate your current sleeping habits?

Please list any specific sleep problems you are currently experiencing:

How many times per week do you generally exercise?

Please list any difficulties you experience with your appetite or eating problems:

Are you currently experiencing overwhelming sadness, grief & depression?

Are you currently experiencing anxiety, panic attacks or have any phobias?

Do you drink alcohol more than once a week?

How often do you engage in recreational drug use?

Have you ever been arrested?

Are you currently in a romantic relationship?

What significant life changes or stressful events have you experienced recently?

Alcohol/Substance Abuse?

Anxiety?

Depression?

Domestic Violence?

Eating Disorders?

Obesity?

Obsessive Compulsive Behavior?

Schizophrenia?

Suicide Attempts?

Are you currently employed?

How would you rate your work satisfaction? 1 being Unsatisfied and 4 being Very satisfied? *

• 1 Unsatisfied
• 2 Somewhat satisfied
• 3 Satisfied
• 4 Very Satisfied

Do you consider yourself to be spiritual or religious?

What do you consider to be some of your strengths?

What do you consider to be some of your weaknesses?

What are your goals for your time in counseling?

Health insurance plan
Medicaid/Other: No Yes Other

Referral info
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