To save time on your first appointment and allow us to spend more time in session, please complete the following form. All information is strictly confidential and will not be shared or viewed by anyone other than your therapist.
Please identify and describe yourself:
Name Date of Birth Sex Male Female
Please provide the following contact information:
Name Title Organization Street Address Address (cont.) City State/Province Zip/Postal Code Work Phone Home Phone E-mail
How did you hear about us? Choose one of the following options:
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1. Please describe the nature of the problem that brings you to counseling.. Include the symptoms you experience and any behavior that results from this:
2. How and when did the problems begin?
3. What have you done so far to cope with the problem? (e.g., medications, therapy, coping strategies)
4. How do the significant people in your life currently feel about, or cope with, your difficulties?
5. What motivates you to work on recovery? How will your life be different when you recover? 6. Are there any disadvantages that you can think of to overcoming the present difficulties? 6. Other important information