About
Assessment
Rates
Contact
Request Consult
About
Assessment
Rates
Contact
Request Consult
Assessment
Name
*
First Name
Last Name
Birth Date
MM
DD
YYYY
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email Address
*
Phone
(###)
###
####
Age
Gender
Geographic Location
Occupation
Married, Single, Divorced
Number of marriages/pregnancies/children
Sexual orientation
How did you hear about me?
What types of psychotherapy or counseling have you done previously, and for how long?
*
What were your primary reasons for seeking therapy, and what were the major issues addressed?
*
Are you on any medications? If so, what are they, and what are they for?
*
Have you been on prescription medications previously for psychological/emotional challenges?
*
Have you ever been hospitalized for psychological/emotional disorders?
*
Do you use tobacco, caffeine, drugs, and/or alcohol? If so, how much and how often?
*
Have you ever had an addiction to substances, porn, sex, eating, etc? If so, how did you work with this and how long has it been since any active addiction?
*
What was your religious upbringing?
*
Current spiritual practice?
*
Are you affiliated with a particular group or religious organization?
*
What were the major challenges or issues in your family dynamics as a child? (Please write at length about this.)
*
What have the major challenges and issues been for you as an adult?
*
Have you experienced any type of abuse? If so, please describe.
*
Have you ever been convicted of a crime? If yes, please describe.
*
Have you ever attempted suicide? If yes, please describe.
*
Any military service? If yes, please describe.
*
Are you currently in an intimate relationship?
*
If currently in an intimate relationship, for how long?
Is your relationship
Check any and all that apply.
Committed
Monogamous
Affairs
If not currently in a relationship, how long since your last one?
What have been the major challenges for you throughout your history of intimate relationships?
*
Please write at least a couple of paragraphs about this.
If you are wanting to work on your current relationship, are both people committed to staying together long-term and going deeper?
What are the primary issues?
What are the main things you would like to address in your work with me? What are you hoping will happen as a result?
*
Please write at least a couple of paragraphs about this.
Your form has successfully submitted.
