Initial Questionnaire

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

Comments

Any thoughts/feelings of wanting to hurt or kill yourself (past or present)?Yes, In the PastYes, CurrentlyNo

Comments

Any current or past self-injurious behavior (cutting, burning, etc.)?
Past: YesNo
Present: YesNo

Comments

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