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Date of birth
Preferred Contact Method
Do you have any current medical conditions?
Are you taking any medications currently?
Have you had any major surgeries or hospitalizations in the past?
Have you used any substances (alcohol, tobacco, drugs) in the past?
Are you currently using any substances?
Have you ever been diagnosed with a mental health condition?
Have you ever been hospitalized for mental health concerns?
Have you ever had thoughts of harming yourself?
Have you ever attempted self-harm?
Are you currently experiencing thoughts of self-harm or suicide?
Do you have a support system (family, friends, community)?
What are you hoping to achieve through therapy?
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