Counseling Form | My Site 3

First name

Last name

Phone

Address

Birthday

Month

Day

Year

Company name

Position

Type of Service

Individual Therapy

Request for Speaking Engagement

History of suicidal thoughts or suicidal attempts? If yes, please share when and specify the details

History of any other mental health diagnosis? (e.g. Depression,Schizophrenia, Bi-Polar, Anxiety). If yes please specify.

History of taking any Medication? If yes please list medication, purpose of medication and dates taking them:*

History of any surgeries? If yes please give date/s and specify type of surgery:

History of psychiatric hospitalizations? If yes please give dates and reason for hospitalization:*

Has anyone close to you told you they believe you have a problem with drugs or alcohol? If yes, who?*

Number of Children. Please list names and ages:*

Country of birth?

Place where you grew up?

Number of siblings within your family?

Your birth order within your family?

Please list all the family members presently living in your household:*

Is there a history of abuse of any kind (emotional, sexual, verbal or physical)? If yes please state what kind of abuse: If yes, were you a victim or a perpetrator?*

Have you ever received counseling for this?If yes, please specify:*

Please state the reason you are considering counseling:

Please state what outcomes you would like to see from participating in counseling:*

Please state any reservations you may have about participating in counseling:

Have you ever been in counseling before? If yes share when and reason:

How did you hear about EncounterHerCounseling?

Counseling Form

Please complete the counseling questionnaire, this will provide the information needed to begin your counseling.