Intake Form Step 1 of 8 12% LinkedInThis field is for validation purposes and should be left unchanged.Your Name(Required) First Last What brings you to grief counseling at this time? Please be as detailed as you can.(Required)What are your goals for grief counseling?(Required)Specify all medications, supplements, and remedies you are presently taking and for what reason.(Required)If taking prescription medication, who is your prescriber? Please include type of license (ex. MD, NP), name and phone number.(Required)Who is your primary care physician? Please include type of license (ex. MD, NP), name and phone number.(Required) Do you drink alcohol? If so, please specify what kind (ex. beer, liquor) how much, and how often.(Required)Do you use recreational drugs? If so, please specify what kind (ex. beer, liquor) how much, and how often.(Required)Have you ever been hospitalized for a psychiatric issue? If so, please elaborate.(Required)Is there a history of mental illness in your family? If so, please elaborate. If you are in a relationship, please describe the nature of the relationship and months or years together.(Required)Describe your current living situation. Do you live alone, with others, with family, etc.(Required)Do you have any children? If so, please note their names and ages.(Required)What is your level of education?(Required)What is your current occupation? How long have you been doing it?(Required)Do you enjoy your work? Why or why not?(Required) What are the stressors in your life right now?(Required)How do you reduce or manage your stress?(Required)How is your sleep?(Required)Do you have suicidal thoughts?(Required) Yes No If you answered “yes” to the question above, have you considered how you might act on these thoughts or when? If so, please explain.(Required)Have you ever attempted suicide? If so, please elaborate.(Required)Do you have thoughts or urges to harm others? If so, please elaborate.(Required) Have you ever had concerns about your eating habits, or been diagnosed with an eating disorder?(Required) Yes No Do you have a spiritual practice?(Required) Yes No What do you do that makes you feel good?(Required)How do you generally manage strong emotions?(Required) Have you ever experienced any of the following? If so, please provide an age and brief description.Physical Injuries (including concussions). Provide Age and Brief Description if so.(Required)Physical Abuse. Provide Age and Brief Description if so.Emotional Abuse. Provide Age and Brief Description if so.Sexual Abuse/Assault. Provide Age and Brief Description if so.Significant Medical or Dental Experiences. Provide Age and Brief Description if so.Birth or Prenatal Trauma (if known). Provide Age and Brief Description if so.Natural Disaster Involvement. Provide Age and Brief Description if so.Motor Vehicle Accidents. Provide Age and Brief Description if so.War/Military. Provide Age and Brief Description if so.Other. Provide Age and Brief Description if so. Please check any of the following you have experienced in the last 6 months: Increased appetite Decreased appetite Trouble concentrating Difficulty sleeping Excessive sleep Low motivation Isolation from others Fatigue/low energy Low self-esteem Depressed mood Tearful or crying spells Anxiety Fear Hopelessness Panic Other (please describe below): Other Symptoms:(Required)Please check any of the following that apply: Headache High blood pressure Gastritis or esophagitis Hormone-related problems Head injury Angina or chest pain Irritable bowel Chronic pain Loss of consciousness Heart attack Bone or joint problems Seizures Kidney-related issues Chronic fatigue Dizziness Faintness Heart valve problems Urinary tract problems Fibromyalgia Numbness and tingling Shortness of breath Diabetes Hepatitis Asthma Arthritis Thyroid issues HIV/AIDS Cancer Other (please describe below): Other Conditions: What does your support system look like? (Example, family, friends, etc)(Required)Have you seen a mental health professional before? If so, how did that go?(Required)What else would you like me to know?(Required)
