Please fill out this entire page and send back to me prior to your first session.
NOTE – I cannot meet with you until this form is completed and signed.
Name: ___________________________________________________
(First) (MI) (Last)
Nickname / Preferred Name: _____________________________________
Birth Date: ______ /______ /______ Age: ________
Gender: □ Male □ Female □ Non-binary (Pronouns: ___________)
Marital Status: □ Never Married □ Partnered □ Married □ Divorced □ Widowed
Number of Children: __________ Ages & Names of Children: _______________________________________
Local Address: ______________________________________________________________
Phone: ( ) Email: __________________________
Referred by: _____________________________
Are you currently receiving psychiatric services or professional counseling elsewhere? □ Yes □ No
If yes, provider’s name: ____________________________
Have you had previous psychotherapy? □ No □ Yes – Previous therapist’s name: __________________________
Are you currently taking psychiatric medication? □ No □ Yes – If yes, list: ________________________________
If no, have you previously taken psychiatric medication? □ No □ Yes – If yes, list: __________________________
Have you ever been hospitalized for psychiatric purposes? □ No □ Yes – If yes, explain: _____________________
Health & Lifestyle Persistent physical symptoms or health concerns: _______________________________________________
Sleep issues? □ No □ Yes – □ Sleeping less □ Sleeping more □ Trouble falling asleep □ Trouble staying asleep
Exercise frequency per week: ________
Appetite/eating concerns? □ No □ Yes – □ Eating less □ Eating more □ Binge eating
Alcohol use frequency: _____________________
Recreational drug use frequency: _____________________
Suicidal thoughts recently: □ Frequently □ Sometimes □ Rarely □ Never
Suicidal thoughts in the past:: □ Frequently □ Sometimes □ Rarely □ Never
Homicidal thoughts: □ Yes □ No
Previous suicide attempts: □ Yes □ No
Other mental health experiences: (circle all that apply)
Extreme depressed mood / Wild mood swings / Rapid speech / Extreme anxiety / Panic attacks / Phobias / Sleep disturbances / Hallucinations / Unexplained losses of time / Unexplained memory lapses / Alcohol/Substance abuse / Frequent body complaints / Eating disorder / Body image problems / Repetitive thoughts / Repetitive behaviors
Relationships & Social Currently in a romantic relationship? □ No □ Yes – Duration: ________
If married, length of marriage: ________
Rate current relationship (1–10): ________
Significant life changes or stressors past 1–3 years: ___________________________________________
Currently employed? □ No □ Yes – Employer/Position: __________________________
Satisfied with current position? __________________________
Work-related stressors: ___________________________________
Religious? □ No □ Yes – Faith: __________________________
Spiritual? □ No □ Yes
Legal & Family History Criminal convictions? □ No □ Yes – Explain: ___________________________________ Family history of (list member):
Depression / Bipolar Disorder / Anxiety Disorders / Schizophrenia / Alcohol/Substance abuse / Eating Disorders / Learning Disabilities / Suicide Attempts
Personal Strengths & Goals Self-esteem rating (1–10): _______
Strengths: _________________________________________
Coping strategies: ________________________________________
Areas to improve: __________________________________________
Therapeutic goals: 1) _____________________________ 2) ___________________________ 3) _________________________
​
LIMITS OF CONFIDENTIALITY
Contents of therapy sessions are confidential. Written or verbal information cannot be shared without your written consent, except: Duty to Warn and Protect – I must notify authorities if you intend to harm yourself or others. Abuse of Children or Vulnerable Adults – I must report suspected or disclosed abuse. Prenatal Exposure to Controlled Substances – Required reporting for potentially harmful exposure. Minors/Guardianship – Parents/legal guardians have access to non-emancipated minors’ records. Substance Use Treatment Records – Federal law (42 CFR Part 2) protects any records related to SUD; I cannot share these without your written consent, except as permitted by law.
I acknowledge and understand the above limits:
Client Signature: _______________________________
Date: _____________________

CANCELLATION POLICY
Appointments canceled with less than 48 hours notice will be billed in full.
Credit Card Type: ☐ Visa ☐ Mastercard ☐ Discover ☐ American Express
Account #: ____ ____ ____ ____
Exp Date: ____ / ____
Security Code: ____
Zip Code: ______ Client Signature: _______________________________
Date: _____________________

NOTICE OF PRIVACY PRACTICES – UPDATED FEBRUARY 16, 2026 How I Use and Share Your Health Information Your personal health information (PHI) is collected and used primarily to: Provide treatment and counseling services Arrange payment for those services Conduct necessary healthcare operations for your care I will not share your information without your written consent, except in situations required by law, including: To prevent a serious threat to your health or safety, or the health and safety of others In response to legal proceedings or court orders When requested by law enforcement officials For workers’ compensation or similar benefit programs Substance Use Treatment Records: If you provide records related to substance use treatment (SUD), these records are federally protected under 42 CFR Part 2. I cannot share these records without your written consent, except as allowed by federal law.
Your Rights Regarding Your Health Information
You have the right to: 1) Request that I communicate with you in a particular way or at a specific location for privacy 2) Request limits on what I share with others involved in your care or payment for care 3) Inspect and obtain copies of your records 4) Request corrections or additions to your records if you believe they are incomplete or inaccurate 5) Receive a copy of this Notice of Privacy Practices 6) File a complaint with me or with the U.S. Department of Health and Human Services if you believe your privacy rights have been violated. This Notice is effective February 16, 2026. Any future updates will be communicated to you.
Acknowledgment of Receipt:
Client Signature: _______________________________
Date: _____________________