Current Name: Pronouns:
Date of Birth: Current Age:
Name on Insurance: Other Names Used:
Primary Language: Secondary Language: Preferred Language:
Primary Phone: Secondary Phone:
May we leaves messages on your phone or email? (appointment reminders, office closures, invoices, etc): Yes No
Employer: Employer Address:
School (current or last attended):
Prescribing Doctor Name: Primary Care Doctor:
Consent for Dr. Glasgow to contact them: Yes No
How will you pay for session?
___Out of Pocket [Cash/Credit Card] *Fee is to be set prior to first session, otherwise full session fee applicable at time of session
If so, please complete the following information:
Claim Phone number:
Copay Listed on Card:
Are you the holder of the insurance plan?
If you are not the holder, please give the NAME, DATE OF BIRTH, and
ADDRESS of the insurance plan holder:
Your fee per sessions is $_________
Living Situation (circle all that apply):
Housing Adequate Incarcerated
Housing Overcrowded Homeless
Housing Dangerous Dependent
Ward of State/Tribal Court At-risk homeless
Degree of comfort in your living situation (1 uncomfortable -- 10 extremely comfortable):
List the members of your household (include pets):
Name Age Relationship
Reason for Treatment:
Briefly describe why you are seeking treatment at this time (include any symptoms of body, mind, or soul)
How long have you been experiencing these symptoms?
How and in what areas of your life do these symptoms get in the way?
What brings on the current symptoms?
What relieves these symptoms?
What other therapies or remedies have you tried?
What outcome do you desire from therapy services now?
List the external supports for your well-being (people, animals, plants, places, activities, things)
List the internal supports for your well-being(your attitudes/beliefs, feelings, sensations, skills/capabilities)
Means of stress relief
Do you engage in movement? How often? What kind?
Does anyone in your family have (Check all that apply & name relationship of member with diagnosis):
Substance Use (indicate if current or past; dose; treatment)
Ever injected drugs? Yes No If yes, which one?
Drug of Choice?
Longest period of sobriety?
Triggers to use:
Past or Current:
Allergies (Medication & Other):
Current Medical Conditions:
Current Medications (include herbs, vitamins, and over-the-counter with dose):
Past Medical History (including hospitalizations/residential treatment, inpatient/outpatient, foster care, aftercare, intensive outpatient, groups)
Dates Inpt/Outpt Location Reason
Current Weight: Current Height: BMI:
Appetite (circle): Good Fair Poor (please explain):
Supportive Social Network? (circle all that apply; Rate 1 weak -5 strong)
No current problems Financial Difficulties
Large indebtedness Poverty/Near poverty
Impulsive Spending Relationship Conflict over Finances
Check the Life Experiences that apply to you (indicate hx for events occurring 3 months or more):
Are you able to care for yourself?
Assistive Devices Needed:
History of Depressed mood: Yes No
History of Suicidal ideation?
History of Suicidal Attempts:
Sleep Pattern: # hours per day Time of onset sleep
Normal Sleeping too much Sleeping too little
Ability to concentrate: Normal Difficulty concentrating
Energy Level: Low Average/Normal High
List significant losses, deaths, abandonment, or traumatic incidents:
Do you practice traditions, spirituality, or religion?
How do you describe your spirituality?
Anything Else Important to Know:
Availability for Treatment:
List all available times each day beginning with first available time. Appointments are scheduled on the hour. Please visit the website to see current hours of operation.
Authorizations and Consent
By signing below, you agree that you have read, understood, and have access to digital copies of the documents below and agree to comply with updates during the duration of your treatment:
1.Acknowledgement of Receipt of the HIPAA:
Print and Sign Date
2. Acknowledgement of Receipt of the Procedures and Policy:
Print and Sign Date
3. Acknowledgement of Receipt of the Consent Agreement:
Print and Sign Date