Therapy

Name

Whatsapp Phone Number

What are effective coping strategies that you have learned?* (required)

Have you had previous psychotherapy?* (required)

1 – yes 2 – no

Do you currently have a primary physician or doctor* (required)

1 – yes 2 – no

Are you currently seeing more than one medical health specialist?* (required)

1 – yes 2 – no

Approximately how long do you exercise for each time?Are you having any difficulty with appetite or eating habits?(required)

1 – yes 2 – no

When was your last physical examination by a physician/doctor? (Select Date)Please list any persistent physical symptoms or health concerns you have (e.g. chronic pain, headaches, hypertension, diabetes, etcu00a0*Are you currently on medication to manage a physical health concern?* (required)

1 – yes 2 – no

In the last year, have you experienced any significant life changes or stressors?* (required)

1 – yes 2 – no

Are you having any problems with your sleep habits? (required)

1 – yes 2 – no

Have you experienced significant weight change in the last 2 months? * (required)

1 – yes 2 – no

Are you currently employed?* (required)

1 – yes 2 – no

In a typical month, how often do you have 4 or more drinks in a 24 hour period? *How often do you engage recreational drug use? * (required)

Daily Weekly Never

Do you consider yourself to be religious?* (required)

1 – yes 2 – no

Are you currently taking prescribed psychiatric medication (antidepressants or others)?u00a0* (required)

1 – yes 2 – no

Are you currently receiving psychiatric services, professional counselling or psychotherapy elsewhere? (required)

1 – yes 2 – no

Have you had suicidal thoughts recently? (required)

1 – frequently 2 – sometimes rarely never

Have you had them in the past? (required)

1 – frequently 2 – sometimes rarely never

Are you currently in a romantic relationship? (required)

1 – yes 2 – no

Do you smoke cigarettes or use other tobacco products? (required)

1 – yes 2 – no

What are your goals for therapy?

What do you like most about yourself?

What do you consider to be your strengths?

Has anyone in your family (either immediate family members or relatives) experienced difficulties with the following? Depression, Bipolar disorder, Anxiety disorder, Panic attacks, Schizophrenia, Alcohol/substance abuse, Eating disorders, Learning disabilities, Trauma history, Suicide attempts, Chronic illness. If yes, please list them below, with the family member.*

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