Please Note: If you are currently having an emergency or any serious thoughts about committing suicide, then please STOP reading right now and call your local suicide hotline, dial 911, or go directly to your local hospital’s emergency room.
Before completing and submitting this information, please read our privacy & confidentiality statement & acknowledge that you understand it and have printed yourself a copy. Yes
Instructions - Please complete this questionnaire using one of the following methods:
1) Print this form, complete it by hand, and bring it with you to the first appointment; OR
2) Transform this into another format, complete the questionnaire, & paste it on your email, then email it directly to me at bill@billhaddock.com
Note: The most private method above is to select the first option.
All sections with an (*) are required fields.
First & last name:
Street address:
PO Box address:
City, State, Zip:
Gender:
Age & DOB:
Marital Status: How long have you been together?
Social Security:_________________
Cell phone:
Home phone:
Email address:
Confirm email address:
Occupation:
Employer:
Are any of your problems affecting your work performance?
Education:
Religious preference:
Name(s) Age/DOB Occupation Relationship
1
2
3
4
5
6
How do prefer we contact you?
Who do you want to be contacted in case of an emergency?
Best phone number of contact person:
How did you find the website?
How were you referred to us?
When did a physician last examine you?
Examining physician’s name:
Name of primary care physician:
Phone:
List all medications you are now taking:
Do you smoke? If so, how many per day?
Have you ever received psychiatric or psychological help or counseling of any kind before?
If you have, please explain briefly:
Briefly describe your primary reason for seeking help:
What are your primary symptoms?
Date symptoms began:
List any stressful events that have occurred in the last year (deaths, marriage, divorces, relationship breakups, changes in work or school, residence, church, etc
What problems do you want to address in counseling?
What have you already done to address the problems?
Please provide any additional information or background you would like to share (history, religious/spiritual issues, etc):
1) your insurance information below;
2) bring your card with you to the first appointment; and
3) contact insurance to make sure you have authorization & that I’m listed as a provider.
Thanks for providing this information. In order to better prepare for the initial session, please read things to may want to know about Dr. Haddock and the helping process.