New Client Questionnaire Please enable JavaScript in your browser to complete this form.123General InformationClient Name *FirstLastDate *Birth Date *Social Security Number *Gender *SelectMaleFemaleGender Non-conformingAddress *Address Line 1CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeHome PhoneMay I leave a message ?Yes/NoYesNoWork PhoneMay I leave a message ?Yes/NoYesNoCell PhoneMay I leave a message ?Yes/NoYesNoEmail *May I email you ? *Yes/NoYesNoPlease note: Email correspondence is not considered to be a confidential medium of communication.Marital Status *SelectNever marriedMarriedDomestic PartnershipSeparatedDivorcedWidowedPlease list any children/ages:Ethnic/racial background:Religious/spiritual background (if any):Employment Status *SelectEmployed (Full time)Employed (Part time)Self-employed (Full time)Self-employed (Part time)UnemployedRetiredHow did you hear about my services? *SelectProfessional referralPsychology TodayYelpGoogle SearchSocial media networkOtherMay I thank this person? *Yes/NoYesNoNextMedical and Psychiatric InventoryHave you previously received any type of mental health services? *Yes/NoYesNoPrevious therapist/practitioner: *Are you currently taking any prescription medication? *Yes/NoYesNoPlease list medication: *Have you ever been prescribed psychiatric medication? *Yes/NoYesNoPlease list and provide dates: *Who is your prescribing physician? *Are you currently experiencing overwhelming sadness, grief, or depression? *Yes/NoYesNoFor approximately how long? Please describe: *Are you currently experiencing anxiety, panic attacks, or have any phobias? *Yes/NoYesNoFor approximately how long? Please describe: *Are you currently experiencing any chronic pain? *Yes/NoYesNoFor approximately how long? Please describe: *How would you describe your current physical health? *SelectExcellentGoodAveragePoorPlease list any specific health problems you are currently experiencing: *How many times per week do you use alcohol? *What do you typically drink and what quantity? *Please describe your past and current use of recreational drugs: *NextFocus of PsychotherapyWhat significant life changes or stressful events have you experienced recently? *What do you consider to be some of your strengths? *What do you consider to be some of your weaknesses? *What brings you to therapy at this time and what are your goals of treatment? *PhoneSubmit
