Name *

First Name

Last Name

Phone *

(###)

###

####

Do you want therapy with another person? *

No, I want therapy for just myself

Yes, with my spouse or partner(s)

Yes, with another member of my family

Are there specific concerns you would like to discuss with your therapist? (Optional. Select all that apply.)

Behaviors I want to change or stop

Life events or experiences

A disorder I want to test for or treat

How I feel

My relationships

Goals for my life

My identity

Are you doing any of the following? (Optional. Select all that apply.)

Avoiding Social Situations

Bullying/Harassing Others

Caregiving/Taking Care of Someone

Cheating/Infidelity

Drug/Alcohol Use

Food/Eating

Gambling

Getting Mad

Hair Pulling/Skin Picking

Hoarding

Internet/Video Game Use

Isolating Myself

Obsessing

Self Harm

Shopping

Sex/Pornography Addiction

Sleep Problems

Smoking

Have you experienced any of the following? (Optional. Select all that apply.)

Abortion

Abuse/Sexual Abuse

Accident

Aging/Getting Older

Assault/Sexual Assault

Bankruptcy/Foreclosure

Career Change/Retirement

Caregiving/Taking Care of Someone

Childhood Trauma/Neglect

Coming Out

Disease/Illness/Chronic Pain

Discrimination

Divorce/Breakup

End of Life

Grief/Loss of Loved One

Immigration/Deportation/Citizenship

Infertility/Miscarriage

Marriage

Moving/Relocation

Natural Disaster

Parenting

Pregnancy/Birth/Adoption/Surrogacy

Starting College

Trauma

Violence

War/Military Service

Which disorder do you want to test for or treat? (Optional. Select all that apply.)

ADD/ADHD

Agoraphobia / Social Anxiety

Anxiety

Autism Spectrum

Bipolar Disorder

Depression

Dermatillomania / Trichotillomania

Eating Disorder

Empathy Deficit Disorder

Hoarding

Identity Disorder

Intellectual or Learning Disability

Mania / Hypomania

Neurological or Developmental Disability

Obsessive Compulsive Disorder (OCD)

Panic Disorder

Personality Disorder

Phobia

Postpartum Depression

Post Traumatic Stress Disorder (PTSD)

Psychosis

Schizophrenia

How do you feel? (Optional. Select all that apply.)

Afraid

Angry

Anxious

Apathetic

Ashamed

Burned Out

Dissatisfied

Emotionally reactive

Grieving

Impulsive

Jittery

Lack of empathy

Lonely

Lost

Mood swings

Obsessive

Overwhelmed

Panicked

Paranoid

Sad

Stressed

Suicidal

Tired

Unattractive

Unhealthy

Unworthy

Withdrawn

Worried

Which relationships do you want to discuss? (Optional. Select all that apply.)

Coworkers

Divorce/Breakup

Family

Friends

In-laws

My Child

My Ex

My Parents/Guardians

My Spouse/Partner

Neighbors

Open Relationships

People I am a caregiver for

Someone I am dating

What goals do you want to pursue? (Optional. Select all that apply.)

Business

Career

Dating

Education

Finances

Finding Meaning in Life

Happiness

Health/Exercise

Recovery

Work/Life Balance

What about you do you want to talk about? (Optional. Select all that apply.)

Aging/Getting Older

Body Image

Feminity

Gender Identity/Transition

Immigrant

Loner

Masculinity

Physical Disability

Race/Ethnicity

Religious/Spiritual Identity

Sexuality

Sexual Orientation

Other

Which of these topics would you like to explore? (Optional. Select all that apply.)

What matters most to you

Patterns of how you think

Your relationships with others

The story you tell about your life

Your dreams

Why you behave the way you do

Your childhood

Your goals

How your body stores stress or trauma

How you find meaning in life

Would you like to learn any of these skills? (Optional. Select all that apply.)

Anger management / compassion

Communication

Conflict resolution

Impulse control

Problem solving

Identifying your needs

Healing from trauma

Stress management

Do you have health insurance you want to use for therapy? *

Yes

No