Silent Partners

Instructions: Please fill out this questionnaire and return it to me by clicking the 'submit' button at the end. All sections with an (*) are Required Fields.
NOTE: If you are concerned about privacy, print this form, complete it, and either mail or bring with you to the first appointment.

*First Name & Last Initial only:

*Gender:

*Age & DOB:

*Marital Status:

Employer:

Employment:

Education:

Religious preference:

*Social Security (leave blank - or fill with zero's, I will get this from you personally):

*Street Address:

*PO Box Address:

*City:

*State:

*Zip Code:

*Cell Phone:

*Home phone (if different):

*Email Address:

*Confirm Email Address:

How did you find the website:

How were you referred to us:

*List members of your family and/or all others who live with you:
Name(s)	Age/Birth date	Occupation	Relationship

*Are any of your problems affecting your work performance?

*May we contact you at:

Work Home (non-emergencies)

*Who do you want to be contacted in case of emergency?

*Daytime Phone:

*Evening Phone:

*When did a physician last examine you?

*Doctor’s name:

*Name of Primary Physician:

*Phone:

*List any major health problems for which you currently receive treatment:

*List any medications you are now taking:

Do you smoke?

Yes No

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:

Date symptoms began:

*Please select any of the following problems that pertain to you:

Nervousness

Suicidal thoughts

Fears

Shyness

Inferiority feelings

Finances

Separation

Sexual problems

Drug use

Friends

Mood swings

Stomach trouble

Divorce

Work

Anger

Sleep

Alcohol use

Stress

Relationships

Unhappiness

Tiredness

Energy

Self-control

Headaches

Loneliness

Legal matters

Memory

Ambition

Temper

Career choices

School problem

Concentration

Marriage

Nightmares

Children

My thoughts

Appetite

Bowel troubles

Making decisions

Depression

Grief

Being a parent

Anxiety

Spiritual

Other:

List any stressful events that have occurred in the last year (deaths, marriage, divorces, changes in work, school, residence, church, etc.)

What problems or difficulties do you wish to address in counseling?

What have you already done to address the problem?

Please provide any additional or background information you would like to share (history, religious/spiritual issues, etc)?

If you plan to use your insurance, please provide your insurance information below and bring your card with you to the first appointment. Thanks.