I look forward to working with you.

Please provide the following information for my records. Leave blank any question you would rather not answer. Information you provide here is held to the same standards of confidentiality as our therapy. If any given question does not apply to you, please put down “n/a” or “none.”

PATIENT DETAILS

* indicates a required field

PATIENT INFO / BACKGROUND
Name*
First Last
Birth Date*
Date Format: MM slash DD slash YYYY
Address*
Street Address City State / Province / Region ZIP / Postal Code Country
Home Phone*
May I leave a message?*
- Yes
- No
Cell Phone*
May I leave a message?*
- Yes
- No
Email*
Enter Email Confirm Email
Age*
Social Security Number*
(necessary for billing)
Name of your Insurance*
(from your insurance card)
Insurance ID #*
Gender*
Marital Status*
Number of Children*
Who referred you to this practice?*
Are you currently in treatment with another mental health provider?*
Are you currently on any psychotropic medication (e.g. anti-depressants, etc.)?*
If so, what are you currently taking? (Please list medication name(s) and dose)?*
Who is prescribing these medications for you?*
If you are not currently on psychotropic medication but you have been, what were you on and who prescribed this for you?*
Have you had psychotherapy/counseling before? If so, who with?*
Are you on any medication at all (not just psychiatric)? If so, what and how much (and what is it treating)?*
HEALTH / SOCIAL / LEGAL HISTORY
How is your physical health?*
Any chronic physical symptoms or health concerns (e.g. chronic pain, headaches, hypertension, diabetes, etc.)?*
Any sleep problems? If so, please describe:*
Do you have a regular wellness/exercise routine? If so, please describe:*
Any problems with appetite or eating? If so, please describe:*
Do you regularly use alcohol? Other substances? If so, please describe (what, how often, how much):*
Have you ever been arrested/convicted of any D.U.I.s? If so, please describe:*
Do you ever thinking about killing yourself? Have you ever attempted to kill yourself? Please, describe:*
Are you having any relational problems? If so, please describe:*
What stresses you out at present/currently? Please, describe:*
Have you ever experienced any of the following?*
(please check all that apply)
- Select All
- Extreme depressed mood
- Wild mood swings
- Rapid speech
- Extreme anxiety
- Panic attacks
- Phobias
- Sleep disturbances
- Hallucinations
- Unexplained losses of time
- Unexplained memory lapses
- Alcohol / substance abuse
- Frequent body complaints
- Eating disorder
- Body image problems
- Repetitive thoughts (e.g. obsessions)
- Repetitive behaviors (e.g. frequent checking, hand-washing, etc.)
- Homicidal thoughts
- Suicide attempt
HOSPITALIZATION HISTORY
Have you ever been psychiatrically hospitalized? If so, voluntarily? Involuntarily? When/where? Please, describe:*
When did the current symptoms start to surface?*
Was there a precipitating event (death, loss, break up, financial issues, etc.) or did the symptoms seem to happen without provocation?*
PROFESSIONAL / OCCUPATIONAL HISTORY
What is your education level?*
What do you do for a living?*
FAMILY MENTAL HEALTH HISTORY
Has any member of your immediate family received any psychiatric/psychological treatment? If so, please describe (for what problem, what type of treatment)?*
OTHER INFORMATION
Please provide as many answers as possible in this section.
What is your first childhood memory? Please provide details such as who, what, when, etc.*
If you had to describe your mother in one word, what would it be?*
And your father?*
How do you feel about yourself?*
How do you cope with moderate to severe stress?*
How do you respond to grief, loss, and/or disappointment?*
What do you hope to get from working together?*
What do you read?*
What do you watch on TV?*
Do you have any pets? If so, how many? And what animal type?*
Do you have a meditation practice?*
What, if any, is your religious/spiritual background?*
DIET / LIFESTYLE / NUTRITION
Please provide as much detail as possible in this section.
Please provide basic information about your daily diet. Do you have food allergies? If so, what are they? Do you drink caffeine? If so, what type and how much? Do you eat processed foods? If so, provide examples.*
Were you breastfed or bottle fed as an infant? (If you do not know, please indicate that.)*
Are you a vegetarian?*
- Yes
- No
If so, do you take a B12 supplement?*
- Yes
- No
If yes, what form(oral, iv, sublingual)?*
Do you take omega-3 fatty acid supplements?*
- Yes
- No
If yes, how much per day?*
Do you eat/drink dairy?*
- Yes
- No
If yes, how much per day?*
Do you eat gluten?*
- Yes
- No
If yes, how much per day?*
Have you had your thyroid tested in the last 6 months?*
- Yes
- No
If yes, please provide me with a copy of those results.*
What types of food do you crave?*
- Sweet
- Savory
- Both
Do you feel you have ample restraint to refrain from these cravings or do they feel out of your control?*
What was the culture of food in your household growing up?*
Do you suffer from eczema, rashes, etc.?*
- Yes
- No
If so, do you recall the treatment?*
Did you ever suffer from chronic ear infections?*
- Yes
- No
If so, do you recall how often you were put on antibiotics?*
Did you struggle with attention related issues in elementary school? Or hyperactivity? If so, how did your school and family help you to manage these symptoms?*
Is there anything else you feel I should know related to how nutrition and food impacts your life?*
Do you feel there is anything I have failed to ask of critical importance? If yes, please elaborate.*

I look forward to working with you.

PATIENT DETAILS

PATIENT INFO / BACKGROUND

HEALTH / SOCIAL / LEGAL HISTORY

HOSPITALIZATION HISTORY

PROFESSIONAL / OCCUPATIONAL HISTORY

FAMILY MENTAL HEALTH HISTORY

OTHER INFORMATION

DIET / LIFESTYLE / NUTRITION

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