New Patient Information
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Email *
Name *
Address *
Best Phone Number to Reach You to leave a message  and/or send a text. *
Date of Birth
What led you to seek services at this time?
Have you had therapy in the past? If so, list names of former clinicians and an estimate of the dates of your work together.
Whom can I thank for referring you to me?
Are you physically healthy or have you had health conditions to manage recently or in the past?
Are you taking any medications?
Do you smoke, drink alcohol, or use recreational drugs, and if so how much, how often?
Please describe your immediate family.
If you have children, please list their names and ages:
If you have siblings, please list their names, ages and your place in the birth order.
Where were you raised? By whom?
Where did you go to school? What degrees have you received?
What do you do professionally?
Have you ever needed to go to an emergency room or hospital for psychiatric care or addiction treatment? 
Is there a history of mental illness, substance abuse, domestic violence, or intergenerational trauma in your family? If so, please describe.
What would you like to accomplish as a result of our work in psychotherapy?
What else would be important for me to know before we meet?
Thank you for taking the time to complete this form. Please expect to be repeating at least some of it verbally to me as well as I will be asking you ALL about your life.  ~Debra
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