Information - Achieve Your Full Potential -

Referred By

Name

Birth Date

MM

DD

YYYY

Age

Address

Street Address City State ZIP Code

Phone Number

Occupation

Preferred method of communicating with me

Voice mail
Email
Text message

Email

Who are you closest to? Who are the supportive people in your life? Who do you live with? [Spouse, partner, roommate, friend, family members]

Are you a parent?

Yes
No

Name and ages of children

What are your goals for therapy?

Have you had therapy before?

Yes
No

Was it helpful for you?

Yes
Somewhat
No

What was the experience like for you?

What are your strengths?

What are the biggest challenges in your life right now?

How would you rate your mood today, if 10 is “Wonderful” and 0 is “I’d rather not be here.”

What’s the lowest it’s been in the last 2 months?

Are you bothered by anxiety/worry?

Yes
No

Please describe your feelings of anxiety/worry.

How do you cope with anger/frustration?

Do you have trouble sleeping at night?

Yes
No

Is there any history of psychological/emotional or drug/alcohol problems in your family? If yes, please describe.

Do you have any health problems/medical conditions?

Yes
No

Please describe your health problems/medical conditions?

If you are an athlete, please list sports injury history.

Are you taking any medications?

Yes
No

Please list the name(s) of your medication(s) and what you take it for.

Is there anything else of importance that you would like me to know about you before we begin?

Yes
No

Please tell me what you would like me to know?

Emergency Contact Information

Whom may I contact in the event of an emergency?

Emergency Contact Relationship

Emergency Contact Phone

Consent for Treatment

Please check the appropriate box: I am the

Client
Guardian
Client's Representative

I agree to enter treatment with Katherine Heeg, LCSW. Our work together will remain completely confidential except as disclosure is required by law. There is a 24-hour notice cancellation policy to avoid being charged. If I am in crisis and am unable to reach her, I will call 911 or go to my nearest emergency room. I understand that she uses new therapeutic modalities. Results are individual and will vary. I have read the information on this website, have communicated with Ms. Heeg regarding her work, and am aware that it is my responsibility to ask questions. The decision to enter treatment and proceed with treatment is mine. My electronic signature represents that I have read and understood these terms and conditions.

My electronic signature represents that I have read and understood these terms and conditions.

I understand
I do not understand