Initial Visit: Questionnaire

Please be as honest as you can so we can get the best possible results.
If any questions come up, please feel free to discuss them during the session.

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Section 1: Basic Personal Information          Today’s Date:
Name:   Birthdate:   Age:   Gender:
Address:
City:   State:   Zipcode:   Email:
Roommates?  / How many?  / Relationship to you?
Ethnicity:   Religion:   Marital Status:
Home #:   Cell #:   Work #:
Preferred # to be reached:
Emergency contact #   Name:   Relationship to contact?
How did you hear about us?
FAMILY MAKEUP:
Any Siblings?  / How many?   Position in sibling lineup?
Any Children?  / How many?
Parents Divorced?  / If so, what age were you?
Both Parents alive?  / Which deceased?
INSURANCE (if applicable):
Insurance carrier type:   ID#   Group #:
Insurance Primary Name:   Relation:   Primary DOB:
Primary Address:   Insured Employer:   Ph#
EDUCATION/EMPLOYMENT:
Highest Educational Level?   Current Occupation if employed?
Do you enjoy work?
Anything stressful regarding your current work role ? (if yes, please explain)
Section 2: Past Behavioral Health Services
Have you previously been in therapy?  / If yes, how long?
Reason?
Were you ever hospitalized for mental health?  / Where?  When?
Previous therapist/practitioner(if applicable):  Contact #:
Permission to contact:
Primary Care Physician:  Contact #:
Section 3 Current Problems:
Please describe the key problems for which you are currently seeking treatment, and when they began. Please feel free to note situations that are difficult for you, as well as problematic moods, thoughts, and behaviors.
Are you currently taking any prescription medication? Yes or No/ If yes, please list with proper dosage
How often have you recently experienced the following? (select the option that best fits how you are currently feeling)
ProblemNeverSometimesOftenAlways
Excessive Sadness
Racing Thoughts
High Energy
Suicidal Thoughts
Homicidal Thoughts
Sense of Hopelessness
Angry Outbursts
Increased Appetite
Decreased Appetite
Sleep Difficulties
Problems related to eating
Hallucinations
Trouble Concentrating
Irritability
High Anxiety
Panic Attacks/ Panic
Avoidance Behavior
Worry /Nervousness
Self-Abuse
Depression
Emotional Numbness
Loneliness
Section 4: Past Medical History Please respond by writing YES for any current or past experiences
Section 5: Family Medical History Have your family members struggled with the following?
ConditionYes / NoFamily Member
Depression
Bipolar
Heart Disease
Diabetes
Cancer
Schizophrenia
Anxiety / Panic Attacks
Eating Disorder
Substance/Alcohol Abuse
Stroke
Seizures
Dementia
Asthma
Blood Pressure
Other:
Section 6: Substance Use: Have you ever used the following substances? Please write YES/NO and fill in (where applicable)
Substance Current Use? / Past Use? Current Amount? Current Frequency? Desire to change?
Alcohol
Marijuana
Cocaine
Amphetamines
Hallucinogens
Tobacco/cigarettes
Other:
Section 7: Additional information
What do you consider to be some of your strengths?
What do you consider to be some of your weaknesses?
Section 8: Any other thoughts/concerns/questions? Feel free to share….