Name *

First Name

Last Name

Phone *

(###)

###

####

May I leave voicemail? *

Yes

No

May I send text messages as needed? *

Yes

No

Mailing address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Birthdate *

MM

DD

YYYY

Primary concerns *

Check all that apply

Behavior

Relationships

Mood

Anxiety

Negative thinking

Vocation

Distraction

Energy

Food

Lifestyle

Purpose/direction

Self-worth

Is your thinking? *

Check all that apply

Positive

Negative

Mixed of positive and negative

Ruminating

Catastrophic

Self-doubt

Worry

Fear for the future

Dark

Intrusive

Have you in the past, or are you currently having active thoughts of harming yourself or someone else? *

Yes, past thoughts of harming myself

Yes, past thoughts of harming others

Yes, current thoughts of harming myself

Yes, current thoughts of harming others

No

Have you in the past, or are you currently having any thoughts of suicide? *

Yes, in the past

Yes, currently

No

Have you ever attempted suicide? *

Yes

No

Have you been in therapy before? *

Yes

No

Do you engage in self care practices? *

Self care can be anything that helps you to relax, manage stress, and be at ease. Examples include: yoga, meditation, drawing, playing a sport, listening to music, riding a bike, baking, karaoke, crafts, prayer, etc.

Yes

No

If you answered no, would you like to learn various self care practices to try?

Yes

No

Complimentary medical practices currently engaging in *

Check all that apply

Acupuncture

Massage

Natropathic medicine

Herbal medicine

Conventional medicine

Psychiatry

Physical therapy

Was filling out this form triggering?

No

Yes

Your name *

First Name

Last Name

Today's date *

MM

DD

YYYY