GENERAL INFORMATION

GENERAL INFORMATION
Email
example@example.com
Please enter your First Name and Last Name:
Who is seeing a therapist select (all that apply):

MyselfSpouseMinor childMinor foster childOther (Explain Below)
Please explain why you want to see a therapist:
Please fill out the form for the person or people who are seeing the therapist.

MarriedSinglelive with partnerSeparatedWidowed
DATE:

MonthDayYear
Date
Name

First NameLast Name
ADDRESS:
CITY
STATE:
ZIP:
DATE OF BIRTH:

MonthDayYear
Date
SOCIAL SECURITY #:
SPOUSE NAME:
SPOUSE ADDRESS IF DIFFERENT FROM ABOVE
SPOUSE DATE OF BIRTH

MonthDayYear
Date
SOCIAL SECURITY #
HOW DID YOU FIND OUT ABOUT LIGHTHOUSE OF HOPE?
Please fill this box if providing information for a minor child.
NAME OF SCHOOL
GRADE
SCHOOLS' ADDRESS
If you have any behavioral issues, kindly list them here.

Many individuals have issues in some of the areas listed below. Please choose the response that best describes you (or your child).

PHYSCICAL FUNCTIONING

	NOT AL ALL	MILD	MODERATE	SEVERE
WEIGHT LOSS
WEIGHT GAIN
OVEREATING
POOR APPITITE
LOSS OF APPITITIE
FATIGUE (LACK OF ENERGY)
SLEEPING TOO MUCH
SPEECH: STUTTER OR STAMMERING
SEXUAL PROBLEMS
DIAGNOSED HEALTH PROBLEMS
UNDIAGNOSED HEALTH PROBLEMS
HEACHACHES
DIFFICULTY SLEEPING

I believe that I am better than others. I believe that I am inferior to others in work and school related thoughts and ideas.

	NOT AL ALL	MILD	MODERATE	SEVERE
SUICIDAL THOUGHTS OR ATTEMPTS
FEARS OF LOOKING FOOLISH
BELIEF THAT I AM BETTER THAN OTHERS
BELIEF THAT I AM INFERIOR TO OTHERS
PROBLEMS CONCENTRATING
MEMORY PROBLEMS
FRIGHTENING THOUGHTS & DAYDREAMS
UNWANTED THOUGHTS OVER AND OVER
SUSPICIOUS OF OTHER PEOPLE’S MOTIVES

FEELINGS AND MOODS

	NOT AL ALL	MILD	MODERATE	SEVERE
WORRY ABOUT HEALTH ISSUES
DEPRESSION
FEAR OF CRITICISM OR DISAPPROVAL
DISCOURAGEMENT /HOPELESSNESS
SUDDEN CHANGES IN MOOD FOR NO APPARENT REASON
GRIEF / LOSS
ANXIETY/NERVOUS NESS
ANXIETY / WORRY
NOT LIKING SELF/NOT LIKING OTHERS

BEHAVIORS

	NOT AL ALL	MILD	MODERATE	SEVERE
GENERAL PERFORMANCE
GENERAL SATISFACTION
NEGATIVE FEELINGS ABOUT WORK/SCHOOL
DIFFICULTY RELATING TO CO WORKERS
DIFFICULTY RELATING TO AUTHORITY
DIFFICULTY RELATING TO SUPERVISOR
ABSENTEEISM

LIFE STRESSORS

	NOT AL ALL	MILD	MODERATE	SEVERE
PHYSICAL ABUSE/DOMESTIC VIOLENCE
LEGAL PROBLEMS
PARENTING PROBLEMS
CHILDHOOD NEGLECT
FINANCIAL STRESS
INTERPERSONAL PROBLEMS
PROBLEMS WITH INTIMACY
SEXUAL ABUSE
ILLNESS OF FAMILY MEMBER
DIFFICULTY WITH DAILY ROUTINES
HYPERACTIVITY
REPEATING CERTAIN ACTS OVER AND OVER
DRUG USE/ABUSE
ALCOHOL USE/ABUSE
LYING
STEALING
DEPENDENCY ON OTHERS TO TAKE CARE OF YOU
ANGER OUTBURST
TEMPER PROBLEMS
VOILENCE AGAINST OTHERS
DIVORCE ISSUES

What do you prefer from your therapist?
Should be Empty: