Psychological Services
Confidential Client Pre Session Form
I know for sure who we dwell on is who we become.
Oprah Winfrey
Complete this confidential pre session form. Take your time and carefully consider your answers. This initial self exploration has been often thought to help a person gain valuable insights into the problems/issues that have brought them to therapy. I will review this before your session so I can be better able to assist you.
Home Address: Street
City, State
Zip
Name:
Email Address:
Age:
Female Male Transgender
Date of Birth: [00/00/0000]
Phone:
Relationship Status:
Married Partner Single Divorced
Have you ever received psychological or psychiatric services?
Yes No
If “yes” please describe:
Level of completed education:
Current employment situation:
Current medications:
If “yes”, please describe:
Questions: Email Support
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© 2006 Calm Waters Psychological Services
Problem Checklist (Check any symptoms that apply whether problem heading is correct or not)
Depression
Chronic sadness
Low frustration tolerance
Crying episodes
Irritability
Feelings of hopelessness
Sleep problems
Difficulty concentrating
Memory problems
Weight loss
Thoughts of suicide
Weight gain
Withdrawing from others
Loss of appetite
Problems functioning at work
Eating too much
Problems functioning socially
Low energy/fatigue
Trouble making decisions
Loss of pleasure/interest
Feelings of worthlessness
Feelings of helplessness
Feelings of guilt
Anxiety
Agitation
Panic attacks
Feeling a need to escape
Fear of leaving home
Excessive worry
Avoidance of public places
Fearfulness
Avoidance of social situations
Trembling/shaking
Pounding heart/palpitations
Fear of loss of control
Restlessness
Fear of dying/impending doom
Phobia (other)
Substance Abuse
Excessive use of alcohol
Excessive use of drugs
Repeated but failed efforts to stop
Family has expressed concern about substance abuse
Increased tolerance
Substance abuse causing problem with work
Health problems because of substance abuse
Legal difficulties (e.g., DUI, possession, etc.)
Blackouts (memory loss)
Daily use
Eating Problems
Obesity (calculate)
Excessive eating
Underweight (calculate)
Self-induced vomiting
Use of laxatives
Obsessing about food, diet, or exercise
Health problems due to underweight or obesity
Family express concern about your weight
Sexual Identity
Feelings of guilt/shame because of same sex attraction
Family stress due to sexual orientation
Relationship difficulties
Gender identity problems
Attention Deficit Hyperactivity/Impulsive
Easily distracted
Problems focusing is interfering with work
Unorganized
Problems with co-workers
Often unable to finish a task
Worried because you can’t focus
Thinking Problems
Fearful others are talking about you
Fearful someone is plotting against you
Racing thoughts
Eccentric
Feelings of not fitting in
Hearing voices others do not hear
Other
Marital problems
Divorce
Parent-child conflict
High risk sexual behavior
Excessive spending
Other:
IF YOU ARE EXPERIENCING SERIOUS SUICIDAL THOUGHTS, PLEASE STOP NOW AND PHONE YOUR LOCAL SUICIDE HOTLINE OR PHONE 911.
PLEASE DESCRIBE BELOW “IN YOUR OWN WORDS” THE PROBLEM(S) YOU HAVE BEEN EXPERIENCING. INCLUDE THE FOLLOWING
· WHEN DID THE PROBLEM START?
· HOW DID IT START?
· WHAT HAVE YOU DONE TO TRY TO SOLVE THE PROBLEM?
· WHAT HAS HELPED [even a little]?
NOW THAT YOU HAVE DESCRIBED YOUR PROBLEM, PLEASE ASK A SPECIFIC QUESTION(S) YOU WOULD LIKE ANSWERED, IN RELATION TO YOUR PROBLEM.
Name of Emergency Contact:
Relationship to you:
This information is required in case of an emergency and will only be used as such. Please refer to the Informed Consent form to review specific information.