Universal Influence

Parent/guardian (if you are a minor):

First Name:

Last Name:

Middle Initial:

Birthdate:

Age:

Gender:

Email:

Telephone:

Marital Status:

May we email you Yes No

May we leave a message Yes No

Referred by: (check any that apply):

Physcology today

Internet search

Family or friend

Website

Another counselor

Physician or Psychiatrist

Are you currently receiving psychiatric services, professional counseling or psychiatric treatment elsewhere? Yes No

Are you currently taking prescribed psychiatric medication (antidepressants or others)? No If yes, please list

If no, have you been previously prescribed psychiatric medication? No If yes, please list

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

List all current medications and dosages (including over-the-counter and naturopathic):

Medication Name Dosage Prescribed Dosage Generally Taken (if different)

Are you having any problems with your sleep habits?
No Yes, if yes, check all applicable

Sleeping too little (average amount)

Poor quality sleep (average amount)

Sleeping too much (avg. amount)

Disturbing dreams (describe)

Early morning wakening (avg. wake time)

How many times per week do you exercise

Approx. how long each time?

Are you having any difficulty with appetite or eating habits?
No Yes, if yes, check all applicable

If yes, check all applicable: Eating less Eating more Binging Restricting

Have you experienced significant weight change in the last 2 months?
Loss Gain Neither

How often do you engage in recreational drug use? Daily Weekly Monthly Rarely Never

Have you had suicidal thoughts recently? Frequently Sometimes Rarely Never

Have you had them in the past Frequently Sometimes Rarely Never

In the past year, have you experienced any significant life changes or stressors? Yes No

Which of the following have impacted you (check all that apply):

Are you currently in a romantic relationship Yes No

How long have you been in this relationship

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

Do you have any children from this relationship, if so - how many?

Have you recently experienced a loss or death? Yes No

State who, how, what and when.

Provide any additional information you would like to share or you feel is significant for your counseling session

Application

Medical Information