Name
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First Name
Last Name
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Date of Birth
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MM
DD
YYYY
Marital Status
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Referred By (if applicable):
Cell Phone
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(###)
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Home Phone
(###)
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Work Phone
(###)
###
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Email
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Do you give permission for messages to be left on your voicemail?
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Best Contact Method
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Significant Other's Name
Significant Dates (eg. Wedding Anniversary)
Dependants/Children/Pets
Number of Children
0
1
2
3
4
5
6
7
8
9
10
Over 10
Age(s) of Children
Family of Origin (Parents/Siblings/Grandparents)
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Describe your home(s) neighborhood(s) growing up: Who are you closest to growing up? Why? Who comforted you growing up? What is/was your relationship like with each? How often do you see...? Is there anyone in your family that you really don't get along with? Is there anyone else who is very close in the family? Or who really don't get along? Any history of family mental health issues?
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Occupation
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Employer Name
Education
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Hobbies
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Spirituality
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Support Systems
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Sleep Patterns
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Recreation/Exercise
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General Health Concerns
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Last Physical
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MM
DD
YYYY
Family Physician
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Medications/Supplements
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How much and how often do you drink alcohol?
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Do you use any other drugs? If so, what ones?
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Any addictions?
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Thoughts of or attempts of suicide?
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Name
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First Name
Last Name
Relationship
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Phone
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(###)
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Overall Physical Health Condition
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Current Prescribed Medications
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Have you ever been diagnosed with a mental health condition?
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If yes, please list:
How would you estimate the severity of the diagnosed condition(s) now?
Have you ever been hospitalized for a mental illness?
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If yes, when?
What issues do you want to address in counselling? When did the problem begin? Has it gotten worse or better over time? Does it have a pattern, i.e., worse in certain contexts or better in certain contexts? What makes it better? What makes it worse? What do you believe is causing or perpetuating the problem? Are there specific issues or goals that you want to work on?
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Finally, what areas of your life are affected? Relationships (family, friends)? Work/school? Physical/recreational activities? Spirituality? Emotions? Life goals? How severe is the impact? What areas are impacted the most? Are there any areas not affected?
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Personal
Family
Relationship
School
Health
Mental Health
Abuse
Addictions
If other, please specifiy:
What brought you in today?
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Any previous counseling experience? How long? What was helpful? What was not helpful?
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Briefly describe the current life experiences you'd like to discuss:
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On a scale of 0 to 10, how would you rate the severity of the pain you are experiencing in the situation right now (physical, mental, emotional & spiritual, relational, financial)?
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1
2
3
4
5
6
7
8
9
10
What’s happening in your storyline, business or immediate life experience, making it important for you to get professional help right now?
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What are people (including family, friends and coworkers) saying about you and your unique life situations, making it important for you to get professional help right now?
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How long have you been in this (physical, mental, emotional & spiritual, relational, financial) state?
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What have you done to remedy the situation? And at what cost?
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Additionally, what sort of counseling and therapy are you currently using or have tried in the past to treat your condition?
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What unspoken stories are you telling yourself to justify, explain and or cope with your unique situation right now in your head?
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Have you already been in therapy for the current situation you'd like to discuss?
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What are your goals and dreams for a better outcome?
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What do you feel are your biggest obstacles to getting better results?
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What’s the major silent frustration you are dealing with during the status quo? In other words, what area of dissatisfaction you are experiencing in your life right now? (ex: Relationship, Parenting, Body image, Work, Finance)
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What’s your dream? What’s your vision of a new life you dream of living?
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What are the most significant reasons that your possibility can’t happen? (What’s the biggest force of resistance keeping you from making major changes and getting your needs met?)
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What are the biggest changes you want to make in your life in the next 3 months?
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What are the biggest changes you want to make in your life over the next 3 years?
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What do you most want to achieve for yourself in your life/career?
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What are the restraining forces keeping you from achieving these?
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What would you say have been your 3 greatest accomplishments to date?
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What do you expect to achieve in life as a result of hiring me as your therapist/life coach?
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What is happening in your marriage, business or life that makes it important for you to get help with it now?
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Have you already been in therapy for the current marital situation you'd like to discuss?
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What do you feel is your biggest obstacle to getting a better result?
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Please read the *informed consent information* below and check this box when done.
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