- I Love Healthy Me

Email

Name

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Telephone Number

What is your why for needing counseling or coaching at this time?

Did anything happen to provoke the need for counseling or coaching? or is this an ongoing situation? Be as detailed as possible.

What are your goals for counseling or coaching?

Is this your first time seeing a Mental Health Counselor/Coach

Yes
No

Have you ever been diagnosed with or evaluated for any of the following? (Check all that apply.)

If you selected other or you suspect you may have one or more of the above please list them here

Have you experienced any of the following? (Check all that apply.)

If you selected other please list the trauma here

Are you under doctor's care, if so what medications and/or supplements you are presently taking and for what reason? Please list herbal supplements as well.

If taking prescription medication, who is your prescribing MD? Please include type of MD, name and phone number.

Do you drink alcohol?

Yes
No

Do you use recreational drugs?

Yes
No

Do you have or have you ever had thoughts of harming yourself?

Yes
No

Have you ever attempted suicide? No Judgement

Yes
No

If yes, please list Approximate date, Method used, Hospitalized? Yes/No

Have you ever been hospitalized for a psychiatric reasons?

Yes
No

If yes, please list Approximate date, Reason for hospitalization, Length of stay

Do you have thoughts or urges to harm others?

Yes
No

Is there a history of mental illness in your family?

Yes
No

If you are in a relationship, please describe the nature of the relationship and months or years together.

Describe your current living situation. Do you live alone, with others. With family, etc...

What is your level of education? Highest grade/degree and type of degree.

Please check any of the following you have experienced in the past six months

Please check any of the following that apply

On average, how many hours of sleep do you get each night?

What are three strengths you believe you possess?

Imagine you received 1 million dollars to pursue your favorite hobby, what would this hobby be?

If our work together is successful, what would be different in your life six months from now?

What else would you like me to know?

Are you okay with incorporating faith-based Christian counseling as part of your treatment plan, this is not forced upon you?

Yes
No