Walk With Me Counseling - Full Background/History
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Name *
Your answer
Address *
Your answer
Email address & phone number *
Your answer
Preferred method of contact *
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Emergency contact (Name and phone number) *
Your answer
Are you currently employed?
If yes, what is your current employment situation?
Your answer
If employed, do you enjoy your work? Is there anything stressful about your current work?
Your answer
Are you currently involved in a romantic relationship?
If yes, for how long?
Your answer
On a scale of 1-5 how would you rate your relationship?
Quite good
Difficult
Do you have children?
If yes, what are their ages?
Your answer
Do you consider yourself to be spiritual or religious?
If yes, describe your faith or beliefs.
Your answer
Are you currently taking any psychiatric medications? *
Required
Is there history of mental health issues in your immediate or extended family?
Your answer
Are you currently experiencing significant grief, sadness or depression?
If yes, please give further detail.
Your answer
Are you currently experiencing anxiety, panic attacks or have any phobias?
If yes, please give further detail.
Your answer
Are you currently experiencing any chronic pain?
If yes, please describe.
Your answer
What significant life changes or stressful events, if any, have you experienced recently?
Your answer
Have you had any issues with abuse of substances (alcohol, prescription or street drugs) in the past?
If so, did you receive treatment for this?
Do you currently struggle with any type of substance use?
If so, please elaborate.
Your answer
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