Today's Date
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Name
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First Name
Last Name
Age
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Date of Birth
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DD
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Address
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Phone
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Email
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Ethnic Identity
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Where did you grow up?
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Emergency contact person (name, relationship, contact info)
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Please describe your current living arrangement (Do you live with others?)
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Have you previously received any type of mental health services?
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If yes, for what reason?
If yes, what was helpful or not helpful?
Have you ever experienced suicidal ideation, suicidal thoughts, or acted on an urge to self-harm or harm others?
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Are you currently employed and/or in school?
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Do you consider yourself spiritual or religious?
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Please describe how your faith or belief supports/helps you
Who is the most supportive person/people/pets in your life currently?
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If someone who truly knows you was asked to describe you in a few words or phrases what might they say?
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This person can be real, imagined, or even a pet
What are your greatest sources of stress currently (in the last two weeks)? How do you cope?
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How would you rate your current sleeping habits?
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Please choose one answer
Please list any difficulties you experience with your eating patterns or your relationship with food:
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What type(s) of physical or body-based movement/activity do you participate in?
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In the last two weeks have you experienced any overwhelming emotions like sadness, grief, depression, anxiety, anger, rage, numbness, or others?
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If yes, for approximately how long did the emotion feel overwhelming?
When was the last time you danced/sang/painted/played/cooked or tried something new?
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What helps you feel relaxed? (think about relaxing sounds, scenes, colors, aromas, etc)
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What would you like to work on in therapy?
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