The Handing Group Counseling Services
Psychotherapy & Coaching
Intake Patient Information
Personal Information
Name*:
NickName*:
Phone*:
Cell Phone*:
Address*:
Email Address*:
Date of Birth*:
Age*:
Employer*:
Relationship Status*:
Sexual Orientation*:
* Required Fields
History
Education: What is the highest grade completed (degree):
Ethnic Origin:
Birth Place:
Religion (Raised in):
Religion (Practicing):
Health
What is your present state of health:
Check all that apply to you:
Periods of Depression:
Difficulty in setting or reaching goals:
Unexplanable fatigue:
Difficulties with anger, hostility, or violence:
Mental Illness:
Difficulties talking with significant others:
Coping with chronic illness:
Amount of time spent on the net:
Use of Alcohol:
Obsessions, Addictions:
Use of Drugs:
Moodiness, sadness, failure, stress:
Other Important Details
Who is part of your support group :
Therapeutic History and Expectations:
What type of therapeutic treatments have you received, if any?
What was your past therapy experience like?
What are your current expectations for therapy?
What prompted you to seek services at this time?
How did you hear about us:
* You will be contacted soon.