top of page


Instructions: To assist me in helping you, please fill out this form as fully and openly as possible. All private information is held in strictest confidence. Form cannot be saved to finish later, so please allot enough time to complete it.  

Demographic & Contact Information

Reason for Today’s Visit


Check boxes below for symptoms that have been frustrating to or otherwise problematic for you during at least the last two weeks:

Alcohol/Substance Use

Current use of each:  

Counseling History

Medical History

Family/Developmental History

Please check any of the following you experienced during childhood:

Thanks for submitting!

bottom of page