Name

Date of Birth

Email

Phone number

Problem

Please provide a description of the problem you are facing.

How long have you been dealing with this problem

• Less than a month

• 1 - 3 months

• 3 - 6 months

• 6 months - 1 year

• 1 - 2 years

How would you rate the intensity of this problem?

Have you experienced any of the following in the past 2 weeks?

• Anxiety

• Difficulty Sleeping

• Lack of Energy

• Appetite Changes

• Guilt

• Hearing Things

• Feelings of Hopelessness

• Loss of Interest in Activities

How would you describe your current mood?

Please select one or more.

• Sad

• Anxious

• Irritable

• Happy

• Calm

Do you have thoughts of harming yourself or others?

Are you dealing with substance abuse?

If yes, please specify:

Are you pregnant?

Who do you live with?

• Alone

• Family

• Partner

• Friends

Do you have a strong support network?

Describe the relationship you have with your family.

Are there any issues at home affecting your well-being?

If yes, please describe:

Detail current medical conditions, surgeries, and allergies (if any)

Are you taking any medications?

If yes, please list down:

Have you had any hospitalizations in the past year?

If yes, please detail:

What do you expect to achieve from your therapy sessions?

Anything else you would like to share that may help us better understand your situation?