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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

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

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Are you currently receiving psychiatric services, professional counselling or therapy elsewhere?
Have you had previous coaching or therapy?
Are you currently taking prescribed psychiatric medication (antidepressants or others)?
Have you been previously prescribed psychiatric medication?

HEALTH AND SOCIAL INFORMATION

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Are you having any problems with your sleep habits?
Check Where Applicable
Are you having any difficulty with appetite or eating habits?
Check Where Applicable
Have you experienced significant weight change in the last 2 months?
Do you regularly use alcohol?
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Are you currently in a romantic relationship?

Have you ever experienced:

Extreme depressed mood:
Wild Mood Swings:
Rapid Speech:
Extreme Anxiety:
Panic Attacks:
Phobias:
Sleep Disturbances:
Hallucinations:
Unexplained losses of time:
Unexplained memory lapses:
Alcohol/Substance Abuse:
Eating Disorder:
Body Image Problems:
Homicidal Thoughts:
Suicide Attempt:
Repetitive Behaviors (e.g., Frequent Checking, Hand-Washing):

OCCUPATIONAL INFORMATION:

Are you currently employed?
Are you happy at your current position?

RELIGIOUS/SPIRITUAL INFORMATION:

Do you consider yourself to be religious?
Do you consider yourself to be spiritual?

FAMILY MENTAL HEALTH HISTORY:

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

Depression
Bipolar Disorder
Anxiety Disorders or Panic Attacks
Schizophrenia
Alcohol/Substance Abuse
Eating Disorders
Learning Disabilities
Trauma History
Suicide Attempts