WS Admin Registration Form

1
Who is completing this form?* This field is required.Please be aware that if the client is an adult then ONLY the client can schedule his/her appointments. If the client is an adult ONLY the client can complete his/her intake documents. Please choose from the drop down below.
The adult client is completing this form.
The minor client's mother is completing this form.
The minor client's father is completing this form.
The adult client's guardian is completing this form.
2
Client's First & Last Name* This field is required.Please enter the client's name below.
First Name
Last Name
3
Client's Initials* This field is required.Please enter the client's initials below.
4
Client's Date of Birth* This field is required.Please enter the client's date of birth below.
Date
Year
Month
Day
5
Client's Cell Phone Number* This field is required.Please provide the client's cell phone number below.
Area Code
Phone Number
6
Client's Email* This field is required.This is the email address that will be used to set up the client portal. Please enter the client's email address below.
example@example.com
7
Does the client have more than one address? For example, does the client have a home address and college address or a mother's home address and a father's home address?* This field is required.Please choose the correct response below.
YESNO
8
Client Address 1* This field is required.Please complete the information below.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
9
Client Address 2Please complete the information below.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
10
First & Last Name of the Client's MotherPlease enter the first & last name of the client's mother below.
First Name
Last Name
11
Date of Birth of the Client's MotherPlease enter the date of birth of the client's mother below.
Date
Year
Month
Day
12
Cell Phone Number of the Client's MotherPlease enter the cell phone number of the client's mother below.
Area Code
Phone Number
13
Email of the Client's MotherPlease center the email of the client's mother below.
example@example.com
14
First & Last Name of the Client's FatherPlease enter the first & last name of the client's father below.
First Name
Last Name
15
Cell Phone Number of the Client's FatherPlease enter the cell phone of the client's father below.
Area Code
Phone Number
16
Email of the Client's FatherPlease enter the email of the client's father below.
example@example.com
17
First & Last Name of the Client's GuardianPlease provide the first & last name of the client's guardian below.
First Name
Last Name
18
Cell Phone of the Client's GuardianPlease provide the cell phone of the client's guardian below.
Area Code
Phone Number
19
Email of the Client's GuardianPlease provide the email of the client's guardian below.
example@example.com
20
Emergency Contact First & Last Name* This field is required.Please provide the first and last name of the client's emergency contact below .
First Name
Last Name
21
Emergency Contact Cell Phone Number * This field is required.Please provide the cell phone number of the client's emergency contact below.
Area Code
Phone Number
22
Emergency Contact Email* This field is required.Please provide the email of the client's emergency contact below.
example@example.com
23
Emergency Contact Relationship to the Client* This field is required.Please describe the emergency contract's relationship to the client.
24
Does The Client Have Access To Reliable Independent Technology To Attend Telehealth Appointments?* This field is required.Please answer YES if the client is able to access technology for telehealth sessions himself/herself reliably. Please answer NO if is not able to access technology for telehealth sessions.
YESNO
25
Does The Client Require Special Accommodations for American With Disabilities Act (ADA) or other needs?* This field is required.Please choose the correct answer below.
YESNO
26
Please Provide Any Additional Information Relevant For WS To Provide The Care & Support The Client's NeedsPlease provide additional information below. If you do not have any additional information to provide then you can simply type N/A in the dialogue box.
27
REASON FOR SEEKING CARE 1: From the client's perspective and in the client's own words, what is the reason for seeking care at this time? * This field is required.Please provide your answer below.
28
REASON FOR SEEKING CARE 2: From the client's perspective and in the client's own words, what happened in the client's life recently that lead to the client wanting to make changes in his/her/their life at this time? Many clients consider pursuing care for quite some time before taking the first step. There is usually a "tipping point" event or "precipitating event" that takes place and facilitates the client to seek care. If that is the case what happened to help the client take the first step.* This field is required.Please provide your answer below.
29
REASON FOR SEEKING CARE 3: From the client's perspective, and in the client's own words, what caused the problems or stressors noted in the reasons for seeking care? * This field is required.Please provide your answer below.
30
REASON FOR SEEKING CARE 4: From the client's perspective and in the client's own words, what actions, skills, resources, assistance, etc have the client tried to address these concerns? Please note if anything has helped the client cope with these problems or stressors even if it was only temporary. Correspondingly, if the client has tried anything to address these concerns that did not help or made the situation worse please provide us with that information. This helps us to understand how to assist you in a timely manner.* This field is required.Please provide your answer below.
31
REASON FOR SEEKING CARE 5: From the client's perspective and in the client's own words, what actions have the client taken that helped the client cope with these problems or stressors- even if it was only temporary. Correspondingly, if the client has tried anything to address these concerns that did not help or made the situation worse please provide us with that information. This helps us to understand how to assist you in a timely manner. We do not want to make recommendations that the client has already tried if they did not work. We also want to ensure that if something helped the client we can build from that to assist the client more expeditiously. * This field is required.Please provide your answer below.
32
REASON FOR SEEKING CARE 6: From the client's perspective and in the client's own words, what are your hopes, goals, and expectations for receiving care? What skills, insights, and resources would you like to learn? What bad or unhealthy habits do you want to stop? What good or healthy habits do you want to begin? Please be specific. If we do not know your clearly defined hopes, goals, and expectations then we will not provide you with the care you seek. If you do not know then please take a moment to reflect. Quite simply, if you do not know your goals then there is no way for us to meet your expectations. We want to set you up for success. Please help us do that. * This field is required.Please provide your answer below.
33
REASON FOR SEEKING CARE 7: From the client's perspective and in the client's own words, how can Wellness Solutions provide you with an ideal client experience? How can WS provide counseling, coaching, psychotherapy, skills, resources, education, etc. to support the client and help him/her/them achieve one's goals? What types of help or skills would the client like to receive? What services or philosophies does WS provide that the client would like to receive?* This field is required.Please provide your answer below.
34
REASON FOR SEEKING CARE 8: From the client's perspective and in the client's own words, if the client could wave a magic wand and everything would be perfect in the client's life what would be different? What barriers are in the client's life that prevents the client from achieving that 'ideal' life? What specific thoughts, feelings, behaviors, stressors, and problems would be resolved, eliminated, mitigated, or changed? Please be specific. * This field is required.Please type your answer below.
35
REASON FOR SEEKING CARE 8: From the client's perspective and in the client's own words, is the client seeking care because he/she/they wants to change, wants help, and is ready to make honest substantive changes OR is the client seeking care at the insistence or behest of another? Is the client seeking care to avoid consequences, such as, relationship or job jeopardy? What level of motivation and commitment does the client have to make changes to one's life at this time? Personal change takes work and will only be as successful as the consistent sustained effort and genuine authentic engagement of the client. There is nothing any professional can do to overcome a client's unwillingness to engage and commit earnestly and honestly to change. * This field is required.Please type your answer below.
36
REASON FOR SEEKING CARE 9: From the client's perspective and in the client's own words, how open and receptive is the client to receiving feedback, especially if this feedback may include that one is responsible for or contributing to their current distress? Counseling is about learning and growing to change one's self to take ownership, responsibility, and accountability for one's behaviors. * This field is required.Please type your answer below.
37
REASONS FOR SEEKING CARE 10: What are the MOST significant problems, stressors, concerns, emotions, or worries impacting your life at this time? (Examples may include: Relationship conflicts, situational or environmental stressors, problems, feelings, or symptoms.)* This field is required.Please complete the information below.
Identified Problem or Stressor (Fill In the Blank)
Rate the Severity (0 Not At All to 5 the Most Severe)
Duration of Problem (How Long has this Been a Problem?)
What is the Frequency this Problem Causes Distress?
1
0 (Not At All)
1
2
3
4
5 (Severe)
1 Week
2 Weeks
3 Weeks
1 Month
2 Months
3 Months
4 Months
5 Months
6 Months
7 Months
8 Months
9 Months
10 Months
11 Months
1 Year
2 Years
3 Years
4 Years
5 Years
6 Years
7 Years
8 Years
9 Years
10 Years
11 + Years
All Day/Every Day
Most of the Day/Every Day
1-3 Days Per Week
4-5 Days Per Week
6-7 Days Per Week
Monthly
2
0 (Not At All)
1
2
3
4
5 (Severe)
1 Week
2 Weeks
3 Weeks
1 Month
2 Months
3 Months
4 Months
5 Months
6 Months
7 Months
8 Months
9 Months
10 Months
11 Months
1 Year
2 Years
3 Years
4 Years
5 Years
6 Years
7 Years
8 Years
9 Years
10 Years
11 + Years
All Day/Every Day
Most of the Day/Every Day
1-3 Days Per Week
4-5 Days Per Week
6-7 Days Per Week
Monthly
3
0 (Not At All)
1
2
3
4
5 (Severe)
1 Week
2 Weeks
3 Weeks
1 Month
2 Months
3 Months
4 Months
5 Months
6 Months
7 Months
8 Months
9 Months
10 Months
11 Months
1 Year
2 Years
3 Years
4 Years
5 Years
6 Years
7 Years
8 Years
9 Years
10 Years
11 + Years
All Day/Every Day
Most of the Day/Every Day
1-3 Days Per Week
4-5 Days Per Week
6-7 Days Per Week
Monthly
4
0 (Not At All)
1
2
3
4
5 (Severe)
1 Week
2 Weeks
3 Weeks
1 Month
2 Months
3 Months
4 Months
5 Months
6 Months
7 Months
8 Months
9 Months
10 Months
11 Months
1 Year
2 Years
3 Years
4 Years
5 Years
6 Years
7 Years
8 Years
9 Years
10 Years
11 + Years
All Day/Every Day
Most of the Day/Every Day
1-3 Days Per Week
4-5 Days Per Week
6-7 Days Per Week
Monthly
5
0 (Not At All)
1
2
3
4
5 (Severe)
1 Week
2 Weeks
3 Weeks
1 Month
2 Months
3 Months
4 Months
5 Months
6 Months
7 Months
8 Months
9 Months
10 Months
11 Months
1 Year
2 Years
3 Years
4 Years
5 Years
6 Years
7 Years
8 Years
9 Years
10 Years
11 + Years
All Day/Every Day
Most of the Day/Every Day
1-3 Days Per Week
4-5 Days Per Week
6-7 Days Per Week
Monthly
1
2
3
4
5
Identified Problem or Stressor (Fill In the Blank)
Rate the Severity (0 Not At All to 5 the Most Severe)
0 (Not At All)
1
2
3
4
5 (Severe)
Duration of Problem (How Long has this Been a Problem?)
1 Week
2 Weeks
3 Weeks
1 Month
2 Months
3 Months
4 Months
5 Months
6 Months
7 Months
8 Months
9 Months
10 Months
11 Months
1 Year
2 Years
3 Years
4 Years
5 Years
6 Years
7 Years
8 Years
9 Years
10 Years
11 + Years
What is the Frequency this Problem Causes Distress?
All Day/Every Day
Most of the Day/Every Day
1-3 Days Per Week
4-5 Days Per Week
6-7 Days Per Week
Monthly
Identified Problem or Stressor (Fill In the Blank)
Rate the Severity (0 Not At All to 5 the Most Severe)
0 (Not At All)
1
2
3
4
5 (Severe)
Duration of Problem (How Long has this Been a Problem?)
1 Week
2 Weeks
3 Weeks
1 Month
2 Months
3 Months
4 Months
5 Months
6 Months
7 Months
8 Months
9 Months
10 Months
11 Months
1 Year
2 Years
3 Years
4 Years
5 Years
6 Years
7 Years
8 Years
9 Years
10 Years
11 + Years
What is the Frequency this Problem Causes Distress?
All Day/Every Day
Most of the Day/Every Day
1-3 Days Per Week
4-5 Days Per Week
6-7 Days Per Week
Monthly
Identified Problem or Stressor (Fill In the Blank)
Rate the Severity (0 Not At All to 5 the Most Severe)
0 (Not At All)
1
2
3
4
5 (Severe)
Duration of Problem (How Long has this Been a Problem?)
1 Week
2 Weeks
3 Weeks
1 Month
2 Months
3 Months
4 Months
5 Months
6 Months
7 Months
8 Months
9 Months
10 Months
11 Months
1 Year
2 Years
3 Years
4 Years
5 Years
6 Years
7 Years
8 Years
9 Years
10 Years
11 + Years
What is the Frequency this Problem Causes Distress?
All Day/Every Day
Most of the Day/Every Day
1-3 Days Per Week
4-5 Days Per Week
6-7 Days Per Week
Monthly
Identified Problem or Stressor (Fill In the Blank)
Rate the Severity (0 Not At All to 5 the Most Severe)
0 (Not At All)
1
2
3
4
5 (Severe)
Duration of Problem (How Long has this Been a Problem?)
1 Week
2 Weeks
3 Weeks
1 Month
2 Months
3 Months
4 Months
5 Months
6 Months
7 Months
8 Months
9 Months
10 Months
11 Months
1 Year
2 Years
3 Years
4 Years
5 Years
6 Years
7 Years
8 Years
9 Years
10 Years
11 + Years
What is the Frequency this Problem Causes Distress?
All Day/Every Day
Most of the Day/Every Day
1-3 Days Per Week
4-5 Days Per Week
6-7 Days Per Week
Monthly
Identified Problem or Stressor (Fill In the Blank)
Rate the Severity (0 Not At All to 5 the Most Severe)
0 (Not At All)
1
2
3
4
5 (Severe)
Duration of Problem (How Long has this Been a Problem?)
1 Week
2 Weeks
3 Weeks
1 Month
2 Months
3 Months
4 Months
5 Months
6 Months
7 Months
8 Months
9 Months
10 Months
11 Months
1 Year
2 Years
3 Years
4 Years
5 Years
6 Years
7 Years
8 Years
9 Years
10 Years
11 + Years
What is the Frequency this Problem Causes Distress?
All Day/Every Day
Most of the Day/Every Day
1-3 Days Per Week
4-5 Days Per Week
6-7 Days Per Week
Monthly
1 of 5
38
Goal Identification* This field is required.Please check all symptoms and goals that you would like to see addressed. For ALL symptoms and goals that you are experiencing rate their level of importance on a scale of 1-5 with 5 as THE MOST IMPORTANT.
0
1
2
3
4
5
Abuse
Academic Concerns/Difficulties
ADD/ADHD
Addiction
Adolescent Concerns
Aging Concerns
Anger
Anxiety
Argumentative
Assertiveness Skills
Behavior Modification or Behavior Change
Blaming Others For One's Problems
Bipolar
Boundaries/Boundary Setting
Codependency
Communication Skills
Compulsive Behaviors
Conduct Problems
Conflict Resolution
Controlling Behavior / Manipulative Behavior Towards Others
Couples Concerns
Decision Making
Depression
Divorce
Difficulty Adjusting To Life Changes
Difficulty Following Rules or Feeling Like Rules Should Not Apply To One's Self
Difficulty Maintaining Stable Housing / Difficulty With Roommates
Difficulty Taking Responsibility For One's Behaviors
Eating/Nutritional Concerns
Employment/Work-Related Stress
Emotionally Sensitive
Entitlement
Establishing A Positive Support system & Routines
Existential Concerns
Family Relationships
Feeling Empty
Feeling Lost
Financial Concerns Influencing Emotional Health
Gender Identity
Grief/Bereavement
Guilt
Healthy Relationships
High Conflict Relationships
Holds Grudges/Difficulty Coping With Real or Perceived Slight
Hopelessness/Helplessness
Homicidal Thinking
Increasing Coping Strategies for Stress
Intrusive Thoughts
Insight
Impulse Control
Legal Concerns
LGBTQ
Life Skills
Loneliness
Loved One With Medical or Mental Illness/Caregiver Concerns
Marital Concerns
Marital Jeopardy
Medical Concerns Influencing Emotional Health
Medication Education
Multiple Failed Relationships
OCD
Paranoia
Peer Related Concerns/Social Isolation
Perfectionism
PTSD/Trauma
Recent Move To A New Home or City
Recovery From Abusive Relationship
Relationships Stress/Difficulties
Resentment
Rigid Thoughts or Behaviors
Seeking Care Due To A Loved One's Insistence
Self-Injury
Selfishness
Suicidal Thinking
Serious Mental Health Concerns
Sleep Problems
Social Skills
Spiritual/Religious Concerns
Wellness Strategies
Abuse
Academic Concerns/Difficulties
ADD/ADHD
Addiction
Adolescent Concerns
Aging Concerns
Anger
Anxiety
Argumentative
Assertiveness Skills
Behavior Modification or Behavior Change
Blaming Others For One's Problems
Bipolar
Boundaries/Boundary Setting
Codependency
Communication Skills
Compulsive Behaviors
Conduct Problems
Conflict Resolution
Controlling Behavior / Manipulative Behavior Towards Others
Couples Concerns
Decision Making
Depression
Divorce
Difficulty Adjusting To Life Changes
Difficulty Following Rules or Feeling Like Rules Should Not Apply To One's Self
Difficulty Maintaining Stable Housing / Difficulty With Roommates
Difficulty Taking Responsibility For One's Behaviors
Eating/Nutritional Concerns
Employment/Work-Related Stress
Emotionally Sensitive
Entitlement
Establishing A Positive Support system & Routines
Existential Concerns
Family Relationships
Feeling Empty
Feeling Lost
Financial Concerns Influencing Emotional Health
Gender Identity
Grief/Bereavement
Guilt
Healthy Relationships
High Conflict Relationships
Holds Grudges/Difficulty Coping With Real or Perceived Slight
Hopelessness/Helplessness
Homicidal Thinking
Increasing Coping Strategies for Stress
Intrusive Thoughts
Insight
Impulse Control
Legal Concerns
LGBTQ
Life Skills
Loneliness
Loved One With Medical or Mental Illness/Caregiver Concerns
Marital Concerns
Marital Jeopardy
Medical Concerns Influencing Emotional Health
Medication Education
Multiple Failed Relationships
OCD
Paranoia
Peer Related Concerns/Social Isolation
Perfectionism
PTSD/Trauma
Recent Move To A New Home or City
Recovery From Abusive Relationship
Relationships Stress/Difficulties
Resentment
Rigid Thoughts or Behaviors
Seeking Care Due To A Loved One's Insistence
Self-Injury
Selfishness
Suicidal Thinking
Serious Mental Health Concerns
Sleep Problems
Social Skills
Spiritual/Religious Concerns
Wellness Strategies
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39
Has The Client Had A Regular Routine Physical Exam From A Medical Professional In The Past 12 Months? (It Is Recommended That All Clients Maintain Regular Visits To His or Her Family Doctor.)* This field is required.Please choose the correct answer below.
YESNO
40
MedicalDoes the client have a current medical presentation of or a previous medical history of problems with any of the following conditions?
Medical Info & History Timing of Symptoms
Symptom Severity (0-5 with 0 as Not At All and 5 as the Most Severe)
Medical Condition / Diagnosis / Symptom Additional Information
Family History of This Medical Concern or Symptom
Allergies
Current
Sporadic
By History
0
1
2
3
4
5
Yes
No
Not Sure
Anemia
Current
Sporadic
By History
0
1
2
3
4
5
Yes
No
Not Sure
Arthritis
Current
Sporadic
By History
0
1
2
3
4
5
Yes
No
Not Sure
Asthma
Current
Sporadic
By History
0
1
2
3
4
5
Yes
No
Not Sure
Autoimmune
Current
Sporadic
By History
0
1
2
3
4
5
Yes
No
Not Sure
Blood Pressure (High/Low)
Current
Sporadic
By History
0
1
2
3
4
5
Yes
No
Not Sure
Broken Bones
Current
Sporadic
By History
0
1
2
3
4
5
Yes
No
Not Sure
Cancer
Current
Sporadic
By History
0
1
2
3
4
5
Yes
No
Not Sure
Cardiac (Heart)
Current
Sporadic
By History
0
1
2
3
4
5
Yes
No
Not Sure
Celiac Disease
Current
Sporadic
By History
0
1
2
3
4
5
Yes
No
Not Sure
Change in Medical Health in Past 12 Months
Current
Sporadic
By History
0
1
2
3
4
5
Yes
No
Not Sure
Cholesterol
Current
Sporadic
By History
0
1
2
3
4
5
Yes
No
Not Sure
Chronic Fatigue Syndrome
Current
Sporadic
By History
0
1
2
3
4
5
Yes
No
Not Sure
Chronic Medical Problems
Current
Sporadic
By History
0
1
2
3
4
5
Yes
No
Not Sure
Chronic Pain
Current
Sporadic
By History
0
1
2
3
4
5
Yes
No
Not Sure
Clostridioides difficile (C. Diff)
Current
Sporadic
By History
0
1
2
3
4
5
Yes
No
Not Sure
Concussion
Current
Sporadic
By History
0
1
2
3
4
5
Yes
No
Not Sure
Confusion
Current
Sporadic
By History
0
1
2
3
4
5
Yes
No
Not Sure
COVID-19
Current
Sporadic
By History
0
1
2
3
4
5
Yes
No
Not Sure
Crohn's Disease
Current
Sporadic
By History
0
1
2
3
4
5
Yes
No
Not Sure
Dementia
Current
Sporadic
By History
0
1
2
3
4
5
Yes
No
Not Sure
Diabetes
Current
Sporadic
By History
0
1
2
3
4
5
Yes
No
Not Sure
Disorientation
Current
Sporadic
By History
0
1
2
3
4
5
Yes
No
Not Sure
Emergency Room Care within the Past 12 Months
Current
Sporadic
By History
0
1
2
3
4
5
Yes
No
Not Sure
Endocrine
Current
Sporadic
By History
0
1
2
3
4
5
Yes
No
Not Sure
Endometriosis
Current
Sporadic
By History