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Personal History

Please rank your concerns in the following areas on a scale of 1 to 10 (0 = No problems and 10 = Major problems). You may use the same number for more than one area.

School and Social Functioning

Do you have a learning disability? If so, what is the disability?

More About You

Are you sexually active?
Do you practice safe sex?
Do you currently drink alcohol? If so, describe the type, amount, and how often (daily, weekly, monthly, etc.).
Do you smoke cigarettes or use any nicotine products? If so, what and how often?
Do you currently use recreational drugs? If so, describe type, amount, frequency
Have you ever been arrested for a D.U.I or other drug related offense? If yes, please give dates and details.
Is it difficult for you to stop or control the amount you drink or use?


Please check any symptoms that you currently experience or have experienced, and indicate when you experienced them.

Psychiatric History

Have you seen a mental health professional before? If so, please specify dates, the reason for counseling, and your experience. What was your diagnosis, if any?
Do you have, or have you ever had, suicidal thoughts?
Have you ever attempted suicide? Please list all attempts and your age when each happened, starting from the most recent event to the oldest event.
Have you ever been hospitalized for a psychiatric issue? If yes, please describe why, when, and the length of your stay.

Do any family members struggle with the following challenges? Please specify which family member.


Family History

Do you have siblings?