Your Name (required)
Nickname (required)
Date of Birth (required)
Gender ---MaleFemaleOther
Phone Number
Is it okay to leave voicemail at this number? YesNo
Is it okay to send texts to this number? YesNo
Address (Street/number)
Address (City/State/Zip)
Your Email (required)
Is it okay to send emails to this address? YesNo
Insurance Provider & ID Number
Amount of Co-pay (if known)
Referral Source College Counseling CenterPrimary Care PhysicianInternet SearchFamily or FriendLIKEMIND websiteOther
Relationship Status MarriedIn a Committed RelationshipDating CasuallySingleDivorcedSeparatedWidowedOther
Employment Status Full-TimePart-TimeFull-Time StudentPart-Time StudentUnemployedOther
Emergency Contact
Relationship to you
Emergency Contact Phone Number
What are the problem(s) for which you are seeking help?
When did you first notice these problems? Within the last monthWithin the last six monthsWithin the last yearOver the last few yearsDuring adolescenceDuring childhood
What are your goals for treatment?
What mental health services are you interested in? Individual PsychotherapyMedication ConsultationGroup TherapyNeuropsychological EvalCouples TherapyADHD EvaluationLearning DisordersOther
Comments
Current Symptoms (Check all that apply) Depressed moodAppetite ChangesMind RacingAnxiety/WorryIrritabilitySuspicious of othersPanic AttacksFatigueSchool/Work ProblemsSleep ProblemsFeelings of GuiltFinancial StressCan't Enjoy ActivitiesRelational ProblemsPoor ConcentrationImpulsive BehaviorOthers
Any thoughts/feelings of wanting to hurt or kill yourself (past or present)?Yes, In the PastYes, CurrentlyNo
Any current or past self-injurious behavior (cutting, burning, etc.)? Past: YesNo Present: YesNo
Have you received mental health services in the past? (Check all that apply) PsychotherapyMedication ManagementGroup TherapyOutpatientInpatientPsychiatricOtherNone
Name of provider/facility, Location of treatment, Approximate dates of treatment & Reason for treatment
Medical History
Current Medications
Personal and Family Medical/Mental Health History YesNo