Deanna Hamby, LPC
Date of birth
Street Address Line 2
State / Province
Postal / Zip Code
Occupation & Employer
Do you have insurance
How many children live with you?
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?
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?
If so, what month/year and for what reason?
Have you ever been suicidal?
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
Relationship with biological father
Were you adopted?
If anyone other than biological parents were especially important in your upbringing, please explain.
Was any family member abusive?
Did any family member have mental health or addiction issues diagnosed or suspected?
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):
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?
Do you drink alcohol more than 1 x per week?
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?
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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