Therapy Charlotte LLC
In preparation for your first appointment, please complete the following form. The information you provide here is protected by law and held in strict confidence.
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Full Name:
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Home Address
Birth Date
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Current Occupation:
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Primary Phone Number
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May I leave a message?
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E-mail Address
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May I e-mail you? (Please note: E-mail correspondence is not considered to be a confidential medium of communication)
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Name of emergency contact:
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Phone number of emergency contact:
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How did you hear about Therapy Charlotte?
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Internet search
Referred by a friend
Psychology Today Directory
Other:
Areas of Concern: Please check all that help describe your concerns or goals.
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Career identity or planning isses
Communication
Conflict-resolution
Decision making
Depression or feeling low
Difficulty concentrating
Feeling "stuck"
Impulse control issues
Managing emotions
Perfectionism or procrastination
Problem solving
Relationship issues
Self-esteem or personal growth
Stress/Anxiety
Struggling to perform in career
Thoughts of suicide or homicide
Other:
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In your own words, why are you here today and what do you want to accomplish?
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