Getting to know you.
As we get to know you, it would be great for you to provide information before our first session which will help us help you. Copy the following page into your writing program on your device and fill in your answers. Send this filled in document to DrCarolFrancis@gmail.com. Thank you for your openness.
Full Name _____________________________________________________ Today’s Date________________________ Date of Birth__________ Age__________
Address (Prime/mailing) _______________________________________________________________________________________ City ________________________________ State _______ Zip Code __________ Home Telephone __________________ Is it OK to contact you at home? __________OK to leave a message? ___________ Mobile Telephone _________________ Is it OK to contact this number? __________OK to leave a message?
____________________________________________________________________________________________Please describe your reasons for seeking help:
How do you handle stressors and/or cope with the problems you have described:
Do you currently have thoughts of harming yourself? □ yes □ no Have you in the past? □ yes □ no If Yes, how long ago? _________________________________________
Any Medical Doctors who are helping you currently? (If desired, addresses, phone numbers, names, specialties and medications or medical procedures they are helping you with currently or within the last 10 years.)
Have you ever had previous therapy/counseling of any kind? □ yes □ no If yes, when, and for how long?
Please check all of the items below that describe your situation:
□ Abuse/trauma – physical, sexual, emotional, neglect □ Aggression, violence □ Alcohol use □ Anger, hostility, arguing, irritability □ Anxiety, nervousness □ Attention, concentration, distractibility □ Career concerns, goals, and choices □ Childhood issues □ Codependence □ Confusion □ Compulsions and/or obsessions (thoughts or actions that repeat themselves) □ Decision-making, indecision, mixed feelings, putting off decisions □ Delusions (false ideas) □ Dependence □ Depression, low mood, sadness, crying □ Divorce, separation, marital conflict, infidelity/affairs □ Drug use – prescription medications, over-the-counter medications, street drugs □ Eating problems – overeating, under-eating, appetite, vomiting □ Emptiness □ Failure □ Fatigue, tiredness, low energy □ Fears, phobias □ Financial or money troubles, debt, impulsive spending, low income □ Gambling □ Grieving, mourning, deaths, losses, divorce □ Guilt □ Headaches, other kinds of pains □ Health, illness, medical concerns, physical problems □ Inferiority feelings □ Impulsiveness, loss of control, outbursts □ Irresponsibility □ Judgment problems, risk taking □ Legal matters, charges, suits □ Loneliness □ Memory problems □ Mood swings □ Oversensitivity to rejection □ Panic or anxiety attacks □ Perfectionism □ Pessimism □ Procrastination, lack of motivation □ Relationships problems (with friends, with relatives, or at work) □ School problems □ Self-centeredness □ Self-esteem □ Self-neglect, poor self-care □ Sexual issues, dysfunctions, conflicts, identity issues □ Sleep problems (too much, too little, insomnia, nightmares) □ Spiritual, religious, moral, ethical issues □ Stress and tension □ Suspiciousness □ Suicidal thoughts □ Temper problems, self-control, low frustration tolerance □ Thought disorganization and confusion □ Threats, violence □ Weight and diet issues □ Withdrawal, isolation □ Work problems, employment issues
Describe your use of alcohol, drugs, or prescription medications?
Has drinking or drug use ever caused you problems in the following areas (check if yes): □ family □ school □ employment □ legal □ emotional □ social □ financial □ behavior □ physical health
Please describe your family and living situation:
Check the statement(s) below that describe the type of family you grew up in: □ overly close family □ no “breathing room” □ everyone was in everyone else’s business □ no privacy □ boundaries not respected □ comfortably close family □ loving □ shared many positive experiences □ supportive □ distant, everyone did their own thing □ not much time spent together □ not a lot of support □ angry, lots of fighting/hostility □ verbal abuse and conflicts □ violence □ frightening □ scared to make mistakes
Please describe traumas, abuse, disasters (natural and manmade) you have experienced during your life.
Please describe your work, education and career(s):
IN CASE OF EMERGENCY, PLEASE NOTIFY:
Name: ______________________________________________ Relationship ___________________________________ Address ___________________________________________________________________________________________ (Street, Apt #) (City) (State) (Zip Code) Telephone # Daytime _______________________________ Evening _________________________________ Cell Phone______________________________