The Being Way

Please fill out the questionnaire below. Leave blank any question you would rather not answer. Information you provide here is held to the same standards of confidentiality stated in our Welcome Form and Privacy Policy.

NEW CLIENT FORM

First Name

Last Name

Thanks for completing this form! We look forward to talking with you

Birth Date

Age

Pronouns

No. of Children

Address

Phone

May we leave a message

Email

May we leave you a email

Are you currently receiving psychiatric services, professional counselling or therapy elsewhere?

No

Yes

Have you had previous coaching or therapy?

No

Yes

Previous coach’s/therapist’s name?

Are you currently taking prescribed psychiatric medication (antidepressants or others)?

No

Yes

Please List Medication

Have you been previously prescribed psychiatric medication?

No

Yes

Please List Previous Medication

HEALTH AND SOCIAL INFORMATION

Please list any persistent physical symptoms or health concerns e.g. chronic pain, headaches, diabetes etc.)

Are you having any problems with your sleep habits?

No

Yes

Check Where Applicable

Sleeping Too Little

Sleeping Too Much

Poor Quality Sleep

Disturbing Dreams

How many times per week do you exercise?

Are you having any difficulty with appetite or eating habits?

No

Yes

Check Where Applicable

Eating Less

Eating More

Binging

Restricting

Have you experienced significant weight change in the last 2 months?

No

Yes

Do you regularly use alcohol?

No

Yes

In a typical month, how often do you have 4 or more drinks in a 24-hour period?

Are you currently in a romantic relationship?

No

Yes

How long have you been in this relationship?

On a scale of 1-10, how would you rate the quality of your current relationship?

In the last year, have you experienced any significant life changes or stressors? (Please list)

Have you ever experienced:

Extreme depressed mood:

No

Yes

Wild Mood Swings:

No

Yes

Rapid Speech:

No

Yes

Extreme Anxiety:

No

Yes

Panic Attacks:

No

Yes

Phobias:

No

Yes

Sleep Disturbances:

No

Yes

Hallucinations:

No

Yes

Unexplained losses of time:

No

Yes

Unexplained memory lapses:

No

Yes

Alcohol/Substance Abuse:

No

Yes

Eating Disorder:

No

Yes

Body Image Problems:

No

Yes

Homicidal Thoughts:

No

Yes

Suicide Attempt:

No

Yes

Repetitive Behaviors (e.g., Frequent Checking, Hand-Washing):

No

Yes

OCCUPATIONAL INFORMATION:

Are you currently employed?

No

Yes

Who is your current employer/position?

Are you happy at your current position?

No

Yes

Please list any work-related stressors, if any:

RELIGIOUS/SPIRITUAL INFORMATION:

Do you consider yourself to be religious?

No

Yes

What is your faith?

Do you consider yourself to be spiritual?

No

Yes

FAMILY MENTAL HEALTH HISTORY:

Has anyone in your family (either immediate family members or relatives) experienced difficulties with the following?

Depression

No

Yes

Depressed Family Member (e.g. sibling, parent, uncle, etc.)

Bipolar Disorder

No

Yes

Bipolar Family Member (e.g. sibling, parent, uncle, etc.)

Anxiety Disorders or Panic Attacks

No

Yes

Anxious Family Member (e.g. sibling, parent, uncle, etc.)

Schizophrenia

No

Yes

Schizophrenic Family Member (e.g. sibling, parent, uncle, etc.)

Alcohol/Substance Abuse

No

Yes

Alcoholic/Substance Abusive Family Member (e.g. sibling, parent, uncle, etc.)

Eating Disorders

No

Yes

Eating Disorder Family Member (e.g. sibling, parent, uncle, etc.)

Learning Disabilities

No

Yes

Learning Disability Family Member (e.g. sibling, parent, uncle, etc.)

Trauma History

No

Yes

Trauma History Family Member (e.g. sibling, parent, uncle, etc.)Add answer here

Suicide Attempts

No

Yes

Suicide Attempts Family Member (e.g. sibling, parent, uncle, etc.)