Today’s Date *

Name *

Date of Birth *

Age *

Address *

City *

Zip *

Home Phone *

Work Phone

Cell Phone

Do I have your permission to leave a voice mail message at these numbers? * YesNo

What is the best number to reach you at? *

Occupation *

Employer *

Highest Grade Level *

Height

Weight

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Spouse’s Name

Spouse’s Age

Children’s Names and Ages

Who may I thank for referring you?

Depressed mood

Overeating / under eating

Feeling keyed up / on edge

Difficulty concentrating

Sleep problems

Low energy

Low self esteem

Difficulty making decisions

Feeling hopeless

Anxiety

Difficulty sleeping

Poor appetite

Feeling shaky

Sexual issues

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Trauma

TBI / Concussion

Internet / Video Game Issues

Current medications and purpose: *

Substances used past 30 days: *

Prior substances used (alcohol or drugs): *

Age of first sexual experience / contact: * 0-45-1010-1212-1616-1818-2121+None

Have you ever been sexually abused? * YesNo

Have you ever been physically abused? * YesNo

Previous Therapy, Counseling or Coaching (place/length): *

Have you ever attempted suicide? *

Have you had suicidal ideas/thoughts? *

Feelings towards mother: *

Feelings towards father: *

Siblings: *

Other significant relationships: *

Religious / spiritual affiliation: *

Current occupation / grade level: *

Describe your reasons for coming to counseling or coaching: *

State your goals for counseling or coaching: *

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