This form is confidential and is designed to help your healthcare professional organize and gather
information about you, your history, and the concerns that have led you to seek treatment. Please fill out
as much as you are able. If, for any reason, you would rather not answer certain questions, feel free to
leave them blank or write in “need to discuss.” Thank you.
Out Of The Items Checked Above, Please List Your Top 3 Concerns In Order Of Importance
Please List The (First) Names And Ages Of Your Immediate Family Members (E.G., Parents, Siblings, Children, Significant Caretakers) and the Quality of the relationship i.e. okay.
Please complete the following about your past (or present) treatment experience(s)
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