First Name Last Name Date Last Name at Birth (If different) Date of Birth DOB Who referred you? Client Phone Number Area Code Phone Number Do we have permission to leave a message at this phone number? Yes No Primary Care Physician: Location: Date of last physician exam: Date Emergency Contact: First Name Last Name Emergency Contact Phone Number: Area Code Phone Number Relationship:
Suicide Risk AssessmentHave you ever had feelings or thoughts of suicide? Yes No Do you currently feel like committing suicide? Yes No How often do you have thoughts of suicide? Have you ever tried to kill or harm yourself in the past? Yes No
Past Medical History:
Past Psychiatric History:
Do you drink alcohol? Yes No How much/often?
Did your parents' divorce? Type option 1 No If yes, how old were you when they divorced? Were any of your parents incarcerated while you were growing up?
Do you have a history of being abused emotionally, sexually, physically, or by neglect?Yes No Please list when and by whom: Do you experience any symptoms directly as a result of past traumas? (Check all that apply) Hypervigilance Difficulty Sleeping Feeling numb or detached Feelings of reliving the events Distress remembering the events Easily startled Difficulty concentrating Blaming self for events Avoiding certain people, places, activities Disturbing memories, thoughts, or imagesQuick to anger Nightmares
Current source of income: blanks . Monthly amount of income: blankHave you ever served in the military? Type option 1 Type option 2 If yes, how long?
If you answered yes to having a DUI, how many? blanks Please provide State Identification Number: blank
Signature: Signature Date Guardian Signature (if under age 14) Signature Date