Questionnaire

 

Please print and answer the following questions before your first session.  (All information provided is confidential)

 

 

Personal

 

Name:                          _______________________________________________________________

Date:                            _______________________________________________________________

Parent/ Legal Guardian (if under 18):   _________________________________________________

Address:                       _______________________________________________________________

Home Phone:               _______________________________________________________________

Cell phone:                   _______________________________________________________________

Birthdate:          ___________________________    Age:   __________________________________

Gender ID:                    _______________________________________________________________

Marital Satus:   □ Single             □ Married       □ Domestic Partnership      □ Never Married    

                          □ Separated      □ Divorced     □ Widowed

How did you find us?  □ Psychology Today       □ Insurance        □ Online Search       

                    □ Referral                       □ Other: ____________

Are you currently employed?       □ Yes    □ No 

           If yes, do you enjoy your work?                □ Yes    □ No 

           Is there anything stressful about your work environment?       □ Yes    □ No 

Are you spiritual or religious?      □ Yes    □ No 

What are some of your strengths?   ___________________________________________________

__________________________________________________________________________________

What are some of your weaknesses?   ________________________________________________

__________________________________________________________________________________

What would you like to accomplish in therapy?   _______________________________________

__________________________________________________________________________________

 

History

Have you previously received any form of mental health services?        □ Yes    □ No 

            If yes, please list the type and practicioner: _____________________________________

__________________________________________________________________________________

Are you currently taking any prescription medication?                            □ Yes    □ No 

            If yes, please list the names and doses: _________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

Have you ever been prescribed psychiatric medication?                        □ Yes    □ No 

            If yes, please list the names and doses: _________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

 

Health

How would you rate your physical health (please circle)?     1    2    3    4    5    6    7    8    9    10

Do you have trouble sleeping?          □ Yes    □ No 

           If yes, please describe the difficutly you have sleeping:  ____________________________

___________________________________________________________________________________

How often do you exercise?   □ Never   □ 1-2x per Week   □ 3-4x per Week   □ Everyday

Do you have any difficulties eating or with your appetite?    □ Yes    □ No 

           If yes, please describe:  _______________________________________________________

__________________________________________________________________________________

Are you currently experiencing overwhelming sadness, grief or depression?    □ Yes    □ No 

           If yes, for how long?  __________________________________________________________

__________________________________________________________________________________

Are you currently experiencing anxiety, panic attacks or phobia espidoes?   □ Yes    □ No 

           If yes, how and when did it begin? _____________________________________________

__________________________________________________________________________________

Do you have chronic pain?    □ Yes    □ No 

           If yes, please describe:  _______________________________________________________

__________________________________________________________________________________

How often do you drink alcohol?  □ Never   □ Rarely   □ Monthly   □ Weekly   □ Daily

How often do you use recreational drugs?  □ Never  □ Rarely  □ Monthly  □ Weekly  □ Daily

Are you in a romantic relationship?    □ Yes    □ No 

           If yes, for how long?  _________________________________________________________

_________________________________________________________________________________

Have you had any significant life changes or stressful events recently?   □ Yes    □ No 

           If yes, please describe?  _______________________________________________________

__________________________________________________________________________________

 

Family History

Please indicate if anyone in your family has had a history of any of the following.  If yes, please indicate which family member in relation to you (i.e. father, grandmother, uncle, etc.)

Alcohol/ Substance Abuse                 □ Yes    □ No                           ________________________

Anxiety                                                 □ Yes    □ No                            ________________________

Depression                                          □ Yes    □ No                            ________________________                                

Domestic Violence                              □ Yes    □ No                           ________________________

Easting Disorders                                □ Yes    □ No                            ________________________

Obesity                                                □ Yes    □ No                            ________________________

Obsessive Compulsive Behavior       □ Yes    □ No                            ________________________

Schizophrenia                                      □ Yes    □ No                            ________________________

Suicide Attempts                                □ Yes    □ No                            ________________________

​

​

​

​