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:Stress Marital Problems Compulsive Behaviors Anxiety Other Relational Problems Seeing Things Others Don’t Panic Physical Abuse Hearing Voices Depression Emotional Abuse Racing ThoughtsApathy Verbal AbuseEating Problems Fatigue/Lack of EnergySexual AbuseDrug UseLoss of Appetite/Overeating Sexual Problems Alcohol UseTrouble SleepingGender Identity Issues Pregnancy Poor ConcentrationAnger Abortion Feeling WorthlessAggressive Behavior Legal Matters Recent Death Bad DreamsWork Stress Grief Unwanted Memories Career ChoicesChronic PainLoss of Control Indecisiveness Loneliness Impulsive BehaviorParenting Problems Fears Controlling Financial ProblemsShyness Controlled by Others Spiritual ProblemsLow Self-Esteem Obsessive Thoughts Other How Distressed would you say you are feeling today? Minimally DistressedModerately distressed Extremely 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