Your Name (required)
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Phone Number
Is it okay to leave voicemail at this number? YesNo
Is it okay to send texts to this number? YesNo
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Is it okay to send emails to this address? YesNo
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Referral Source College Counseling CenterPrimary Care PhysicianInternet SearchFamily or FriendLIKEMIND websiteOther
Relationship Status MarriedIn a Committed RelationshipDating CasuallySingleDivorcedSeparatedWidowedOther
Full-TimePart-TimeFull-Time StudentPart-Time StudentUnemployedOther
Emergency Contact
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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
Depressed moodAppetite ChangesMind RacingAnxiety/WorryIrritabilitySuspicious of othersPanic AttacksFatigueSchool/Work ProblemsSleep ProblemsFeelings of GuiltFinancial StressCan't Enjoy ActivitiesRelational ProblemsPoor ConcentrationImpulsive BehaviorOthers
Yes, In the PastYes, CurrentlyNo
YesNo Present: YesNo
PsychotherapyMedication ManagementGroup TherapyOutpatientInpatientPsychiatricOtherNone
Current Medications
Personal and Family Medical/Mental Health History YesNo