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*Please note: Email Correspondence is not considered to be confidential medium of communication.

Gender:
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History

Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc.)?
Are you currently taking any prescription medication?
Have you ever been prescribed psychiatric medication?

General and Mental Health Information

1. How would you rate your current physical health? (Please select one)
2. How would you rate your current sleep habits?
5. Are you currently experiencing overwhelming sadness, grief, or depression?
6. Are you currently experiencing anxiety, panic attacks or have any phobias?
7. Are you currently experiencing any chronic pain?
8. Do you drink alcohol more than once a week?
9. How often do you engage in recreational drug use?
10. Are you currently in a romantic relationship?

Family Mental Health History

In the section below, identify if there is a family history of any of the following. If yes, please indicate the family member’s relationship to you in the space provided (e.g. father, grandmother, uncle, etc.)

Alcohol/Substance Abuse
Anxiety
Depression
Domestic Violence
Eating Disorders
Obesity
Obsessive Compulsive Behavior
Schizophrenia
Suicide Attempts

Additional Information

1. Are you currently employed?
2. Do you consider yourself to be spiritual or religious?

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