First
Name * : |
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Last
Name * : |
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Gender
* : |
Male
Female |
Age
* : |
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Date
of Birth * : |
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Home
Phone * : |
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Email Address * : |
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| Relationship
Status* :
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Single
Married
Divorced |
Education
* : |
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Home
Address * : |
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1.
What Brings you here ? |
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2. What would you like to achieve from counseling? |
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3.
Are you taking any medications? If yes, please list the names
of medication and the purpose of medications taken.
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4.
Have you obtained Psychiatric or Counseling services before?
If yes, please describe?
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5.
What are your Strengths? |
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check the box that applies to you: |
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Ulcer |
Job Change |
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Tense |
Divorce |
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Nervous |
Stuck in a rut |
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Trouble Sleeping |
Lonely |
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Thoughts of Self harm |
Sadness |
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Thoughts of harm to others |
Angry |
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Headaches |
Hearing things that are not really there |
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High blood pressure |
Seeing things that are not actually present |
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Social withdrawal |
Drug abuse |
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Loss of interest in activities enjoyed previously |
Memory Loss |
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Under eating |
Engage in Self- injurious behavior |
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Overeating |
Low Self- esteem |
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Excessive worrying |
Racing thoughts |
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Survivor of sexual abuse |
Survivor of physical abuse |
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Restlessness |
Impulsive behavior |
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Loss of meaning in life |
Alcohol Abuse |
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Nightmares |
Low energy |
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Shyness |
Believe that someone is out to get you |
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Marital Conflict |
Excessive Spending |
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Yes, I have read the Disclaimer and Privacy Policy, and agree
with its terms and conditions.
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