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By signing the following document electronically, it is to be the legally binding equivalent of your individual handwritten signature.



Can we E-mail you?

How do you prefer to be contacted? (check one)

Can we text you on your cell phone?

Can we discuss your appointment times with your spouse/child?

Can we thank them for the referral?

Do you want faith/spiritual issues incorporated into the counseling process?

Are you currently employed?

Please rate the severity of your present concern: (check one)

Have you received counseling, psychiatric or psychological treatment before?

Were the results positive?

Have you been diagnosed or treated for any type of mental illness?

Have you received inpatient care?

Have you suffered any form of abuse?

Have you ever attempted suicide?

Have you ever, or are you currently self-mutilating/self-harming?

How would you rate your current physical health? (Check one)

Are you currently experiencing any physical problems? (e.g. headaches, body aches, stomach problems,)

Are you currently sexually active?

Marital Status

Do you have any pending legal charges?

Have you or your child ever been convicted of anything other than a misdemeanor?

Have you ever abused drugs?

Have you ever abused alcohol?

Do you drink alcohol?