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Services in Connecticut
Addiction and Early Recovery
Long-Term Recovery
Outside Connecticut
Addiction and Early Recovery
Long-Term Recovery
About
Contact
Contact:
860-989-1683
email
Home
Services in Connecticut
Addiction and Early Recovery
Long-Term Recovery
Outside Connecticut
Addiction and Early Recovery
Long-Term Recovery
About
Contact
Home
Services in Connecticut
Addiction and Early Recovery
Long-Term Recovery
Outside Connecticut
Addiction and Early Recovery
Long-Term Recovery
About
Contact
Ready to start on the road to recovery?
Please fill out and submit this form, and we can begin your healing journey
I understand that insurance is not accepted
Name
Email Address
History
Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc.)?
Yes
No
If Yes, and you would like to share more about those services, please do so here:
Are you currently taking any prescription medication?
Yes
No
If yes, please list and provide reason:
Have you ever been prescribed psychiatric medication?
Yes
No
If yes, please list and provide reason and dates:
Have you ever suffered any traumatic physical injury, e.g. accidents or significant injuries from sport or recreational activities?
Yes
No
If yes, please describe briefly with dates:
Have you ever suffered any emotional trauma that you believe I should know about, even if you’re not willing or ready to discuss it?
Yes
No
If yes, please provide words or phrases that we can use to refer to them. They could be dates that you would recognize, short descriptions or anything that would bring it to mind if I mentioned it. Also, note if you are not willing or ready to discuss it.
Please describe briefly what brings you to therapy:
General and Mental Health Information
How would you rate your current physical health?
Poor
Unsatisfactory
Satisfactory
Good
Very Good
Please list any specific health problems you are currently experiencing:
How would you rate your current sleeping habits?
Poor
Unsatisfactory
Satisfactory
Good
Very Good
Please list any specific sleep problems you are currently experiencing:
How many times per week do you generally exercise?
What types of exercise do you participate in?
Please list any difficulties you experience with your appetite or eating problems:
Are you currently experiencing overwhelming sadness, grief or depression?
Yes
No
If yes, for approximately how long?
Are you currently experiencing anxiety, panics attacks or have any phobias?
Yes
No
If yes, when did you begin experiencing this?
Are you currently experiencing any chronic pain?
Yes
No
If yes, when did you begin experiencing this?
Do you drink alcohol more than once a week?
Yes
No
How often do you engage in recreational drug use?
Are you in recovery? If so, for how long?
Are you currently in a romantic relationship?
Yes
No
If yes, for how long?
. On a scale of 1-10 (with 1 being poor and 10 being exceptional), how would you rate your relationship?
1
2
3
4
5
6
7
8
9
10
Why did you choose that?
What significant life changes or stressful events have you experienced recently?
Family Mental Health History
In the section below, identify if there is a family history of any of the following. If yes, please indicate the family member’s relationship to you in the space provided (e.g. father, grandmother, uncle, etc.)
Alcohol/Substance Abuse
Yes
No
Relationship
Anxiety
Yes
No
Relationship
Depression
Yes
No
Relationship
Domestic Violence
Yes
No
Relationship
Eating Disorders
Yes
No
Relationship
Obesity
Yes
No
Relationship
Obsessive Compulsive Behavior
Yes
No
Relationship
Schizophrenia
Yes
No
Relationship
Suicide Attempts
Yes
No
Relationship
Alcohol/Substance Abuse
Yes
No
Relationship
Times
Additional Information
Are you currently employed?
Yes
No
If yes, what is your current employment situation?
Do you enjoy your work? Is there anything stressful about your current work?
Do you consider yourself to be spiritual or religious?
Yes
No
If yes, describe your faith or belief:
What do you consider to be some of your strengths?
What do you consider to be some of your weaknesses?
What would you like to accomplish from your time in therapy?
Is there anything else you think I should know before we begin therapy?
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