Client's Full Name

Phone Number

Email Address

Date of Birth (D.O.B.)

Parent/Guardian's Name

Reason for Referral

Describe your level of stress and what you have done to cope with stress in the past

Describe your current support system

Any History of: Any History of: Sexual Abuse Mental Illness Physical Abuse Domestic Violence Emotional Abuse Religious

Are You Currently in a Dangerous Environment? Are You Currently in a Dangerous Environment? Yes No Not Sure

Any History of Addiction, Sampling Drugs or Alcohol?

Any history of committing a crime

Are you currently on probation Are you currently on probation Yes No

Any history of addiction or sampling drugs or alcohol? Any history of addiction or sampling drugs or alcohol? Yes No

If yes, what have you done in the past to deal with the addiction?

Do you attend any support groups? Do you attend any support groups? Yes No

Do you currently have a sponsor? Do you currently have a sponsor? Yes No

Have you ever been in a treatment program or sought counseling before? Have you ever been in a treatment program or sought counseling before? Yes No

If yes, what worked and what didn't work for you in prior treatment?

Do you have any medical issues that would interfere with counseling at this time?

Do you have a history of depression? Do you have a history of depression? Yes No

At what age, did you first start feeling depressed?

Do you have a history of anxiety? Do you have a history of anxiety? Yes No

At what age, did you first start feeling anxiety?

Do you have a history of self harm? Do you have a history of self harm? Yes No

At what age, did you first start hurting yourself?

Do you have a history of an eating disorder? Do you have a history of an eating disorder? Yes No

At what age, did you first start experiencing an eating disorder?

Are you involved in any outside activities? Are you involved in any outside activities? Yes No

How often do you engage in physical exercise? How often do you engage in physical exercise? Yes No

Do you have difficulty talking about your feelings? Do you have difficulty talking about your feelings? Yes No Sometimes

Do you have difficulty sleeping? Do you have difficulty sleeping? Yes No

What time do you generally go to sleep during the week?

Do you have problems concentrating to finish homework? Do you have problems concentrating to finish homework? Yes No Sometimes

Do you have problems controlling intense emotions? Do you have problems controlling intense emotions? Yes No Sometimes Around Certain People

Have you had thoughts of severely harming someone else? Have you had thoughts of severely harming someone else? Yes No Sometimes

Do you have a history of being bullied? Do you have a history of being bullied? Yes No

If yes to being bullied... If yes to being bullied... Past Present

Have you had any thoughts of suicide? Have you had any thoughts of suicide? Yes No

If yes to suicide thoughts... If yes to suicide thoughts... Past Present