Please enable JavaScript in your browser to complete this form.Name *FirstLastSexMaleFemaleAgeWrite in numbersPhone NumberEmail *FAMILY INFORMATION/HISTORYPlease list your father, mother, sisters, brothers, step family relations, or other family members who had a significant effect on your life (either positive or negative).NAMERELATIONSHIPDESCRIPTIONSingle Line TextSingle Line TextDESCRIPTIONSingle Line TextSingle Line TextDESCRIPTIONSingle Line TextSingle Line TextDESCRIPTIONSingle Line TextSingle Line TextDESCRIPTIONSingle Line TextSingle Line TextDESCRIPTIONHAVE YOU SEEN A COUNSELOR BEFORE?YesNoif yes please list here belowName of CounselorDateHave your family mebers or friends ever attempted or commited suicide?YesNoIf yes, who?If yes, when?PRESENT ISSUES AND GOALSCheck any of the following symptoms or problems that you currently are or recently have experienced:StressMarital ProblemsCompulsive BehaviorsAnxietyOther Relational ProblemsSeeing Things Others Don’tPanicPhysical AbuseHearing VoicesDepressionEmotional AbuseRacing ThoughtsApathyVerbal AbuseEating ProblemsFatigue/Lack of EnergySexual AbuseDrug UseLoss of Appetite/OvereatingSexual ProblemsAlcohol UseTrouble SleepingGender Identity IssuesPregnancyPoor ConcentrationAngerAbortionFeeling WorthlessAggressive BehaviorLegal MattersRecent DeathBad DreamsWork StressGriefUnwanted MemoriesCareer ChoicesChronic PainLoss of ControlIndecisivenessLonelinessImpulsive BehaviorParenting ProblemsFearsControllingFinancial ProblemsShynessControlled by OthersSpiritual ProblemsLow Self-EsteemObsessive ThoughtsOtherHow Distressed would you say you are feeling today? Minimally DistressedModerately distressedExtremely distressedAre you currently experiencing any desire to die?YesNoHave you experienced any desire to die in the past?YesNoHave you attempted suicide in the past?YesNoAre you currently experiencing any harmful or fearful feelings?YesNoWhat do you hope to gain from this counseling experience?Submit