Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Date of Birth *

MM

DD

YYYY

Relationship Status *

Single

Married

Separated

Divorced

Widowed

Highest Level of Education Completed *

High School / GED

Associate's Degree

Bachelors

Masters

Doctorate

Have You Previously Received Any Type of Mental Health Services (Psychotherapy, Psychiatric Services, Etc.)? *

Yes

No

Are You Currently Taking Any Prescription Medication? *

Yes

No

Have You Ever Been Prescribed Psychiatric Medication? *

Yes

No

How Would You Rate Your Current Physical Health? *

Poor

Unsatisfactory

Satisfactory

Good

Very Good

How Would You Rate Your Current Sleeping Habits? *

Poor

Unsatisfactory

Satisfactory

Good

Very Good

How Many Times Per Week Do You Generally Exercise? *

Zero - I Am Not Exercising At This Time

Once A Week

Twice A Week

Three Times A Week

Four Times or More

Are You Currently Experiencing Any Difficulties With Your Appetite or Eating Patterns? *

Yes

No

Are You Currently Experiencing Overwhelming Sadness, Grief or Depression? *

Yes

No

Are You Currently Experiencing Anxiety, Panic Attacks or Have Any Phobias? *

Yes

No

Are You Currently Experiencing Any Chronic Pain? *

Yes

No

Do You Currently Drink Alcohol More Than Once A Week? *

Yes

No

How Often Do You Engage In Recreational Drug Use? *

Daily

Weekly

Monthly

Infrequently

Never

Are You Currently In A Romantic Relationship? *

Yes

No

Alcohol/Substance Abuse *

Yes

No

Anxiety *

Yes

No

Depression *

Yes

No

Domestic Violence *

Yes

No

Eating Disorders *

Yes

No

Obesity *

Yes

No

Obsessive-Compulsive Disorder *

Yes

No

Schizophrenia *

Yes

No

Suicide Attempts *

Yes

No

Are You Currently Employed? *

Yes

No

Do You Consider Yourself To Be Religious or Spiritual? *

Yes

No

Today's Date *

MM

DD

YYYY