Personal Information Full Name Date of Birth Email Address Phone Number Address Emergency Contact Name Emergency Contact Phone

Background Information How did you hear about us? Occupation Relationship Status Single Married Divorced Widowed Other

Presenting Concerns Please describe the main reasons you are seeking therapy When did these issues begin?

Medical & Mental Health History Have you previously attended therapy? Yes No If yes, when and for how long? Are you currently taking any medication? Yes No If yes, please list Any history of psychiatric hospitalization? Yes No

Additional Information Anything else you’d like your therapist to know?