Deanna Hamby, LPC
www.deannahamby.com
Name
First Name
Last Name
Date of birth
-
Month
-
Day
Year
Date
Email
example@example.com
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Occupation & Employer
Employment Status
Please Select
Full-time
part-time
school
retired
unemployed
other
Do you have insurance
Yes
No
Living situation
Please Select
Alone
Friend(s)
Parent(s)
Partner/Spouse
How many children live with you?
Please Select
1
2
3
4+
Emergency contact name, relationship, and phone number
Who were you referred by?
What is the main reason you are here today?
When did this first begin?
Have you been in psychotherapy before?
Yes
No
If so, what was helpful or not about therapy in the past?
Please list any past mental health diagnoses
Have you ever been hospitalized for psychological reasons?
Please Select
Yes
No
If so, what month/year and for what reason?
Have you ever been suicidal?
No
Yes, without actions
Yes, with actions
Do you have any current safety concerns (i.e. suicidality, domestic violence)? If yes, please explain.
List current or past psychotropic medications.
Relationship with biological mother
Please Select
Supportive
Acceptable
Poor
No relationship
Deceased
Other
Relationship with biological father
Please Select
Supportive
Acceptable
Poor
No relationship
Deceased
Other
Were you adopted?
Yes
No
If anyone other than biological parents were especially important in your upbringing, please explain.
Was any family member abusive?
Yes
No
Did any family member have mental health or addiction issues diagnosed or suspected?
Yes
No
Please explain any family history of mental health or addiction issues.
Please check any types of trauma that you may have experienced (if you are comfortable sharing that at this time):
Physical
Sexual
Emotional
Verbal
Other
Are you aware of any issues at the time of your birth (i.e. prematurity, extended hospital stay)? If so, please explain.
List any physical health issues or past surgeries
List any medications for physical health issues
Do you use tobacco?
Yes
No
Do you drink alcohol more than 1 x per week?
Yes
No
If so, how much do you drink and how often? And does this concern you?
Please list any other drugs you use, how much, and how often.
Are you or have you been in recovery for an addiction?
Yes
No
List current or past legal issues
Explain any current issues with housing, employment, or education?
Who do you consider your support system?
What are your hobbies, interests, or leisure activities?
What are your goals for therapy?
Use this space for anything else we may have missed, but you want to be sure that I know.
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