New Client Biography

Step 1 of 2

MM slash DD slash YYYY
MM slash DD slash YYYY
Sexual Orientation
Bariatric Surgery?
Have you received therapy in the past?
Names and ages of my children
Medications, Dosages, and Purpose of each
Would you like to have your religious beliefs incorporated into counseling?
Were you adopted or raised with parents other than your natural parents?
Your Mother Or Mother Figure
Is there anything unusual about your relationship with your mother?
Your Father Or Father Figure
Drug experience
Thoughts and Behaviors
Please check how often the following thoughts occur to you
1) I want to die.
2) I want to hurt someone.
3) I am going crazy.
4) People hear my thoughts.
5) Someone is watching me.
6) I hear voices in my head.
7) I am out of control.
8) I am so depressed.
9) God is disappointed in me.
10) I can’t be forgiven.
11) Life is hopeless.
12) No one cares about me.
13) I am lonely
14) I am a failure.
15) Most people don’t like me.
16) I am so stupid.
17) I can’t concentrate.
18) Why am I so different?
19) I can’t do anything right.
20) I have no emotions.
Please check the thoughts, behaviors , and symptoms that occur more often than you would like.

© 2024