Name
First, Middle, Last

Date of Birth
(MM/DD/YYYY)

Age

Gender

Marital Status

Number of Children and Ages

Current Address
City, State, Zip Code

Home Phone Number

May we leave a message? 

Cell Phone / Other

May we leave a message?

Work Phone Number

May we leave a message?

Email Address

May we email you?
*NOTE: Emails may not be confidential*

Who may we contact in case of an emergency?
Name and Phone Number

Referred by:

Are you currently receiving psychological services, professional counseling, psychiatric services, or any other mental health services?

If so why:

With Who:

Are you currently taking any psychiatric prescription medication? 

If yes, please list:

Have you been prescribed psychiatric prescription medication in the past?

If yes, please list:

Have you been psychiatrically hospitalized in the past?

If yes, please list dates and locations:

Please provide the name, address, and telephone number of your primary care physician. 

How is your physical health at the present time?

Please list any persistent physical symptoms or health concerns (e.g. chronic pain, headaches, hypertension, diabetes, thyroid dysfunction, etc.): 

Are you on any medication for physical/medical issues?

If yes, please list:

Are you having any problems with your sleep habits?

Are there any changes or difficulties with your eating habits?

Have you experienced a weight change in the last two months?

Do you exercise regularly?

If yes, how many days per week do you exercise? How many mins/hrs. per session?

Do you consume alcohol regularly?

In one month, how many times do you have four or more drinks in a 24-hour period?

How often do you engage in recreational drug use?

What kinds of recreational drugs do you use?

Are you currently in a romantic relationship?

If yes, how long have you been in this relationship?

On a scale from 1-10 (10 being great), how would you rate the quality of your relationship?

In the last year, have you had any major life changes (e.g. new job, moving, illness, relationship change, etc.)?

Have you felt depressed recently?

Have you had any suicidal thoughts recently?

If yes, how often?

Have you ever had suicidal thoughts in your past?

If yes, how long ago?

How often did you have these thoughts?

Depression

Suicide

Anxiety Disorders

Bipolar Disorder

Panic Attacks

Alcohol/Substance Abuse

Eating Disorder 

Trauma History

Domestic Violence

Sexual Abuse

Obesity

Obsessive Compulsive Behavior

Schizophrenia

Do you practice a religion?

If yes, what is your faith?

Are you currently employed?

If yes, who is your employer?

What is your position?

Are you happy in your current position?

Does your work make you stressed?

If yes, what are your work-related stressors?

List your strengths and what you like most about yourself

List areas you feel you need to develop

What are some ways you cope with life obstacles and stress?

What are your goals for this course / what would you like to accomplish?

I am acknowledging that I have chosen to receive sex addiction & mental health services in the form of online education and coaching from Newlife Psychology. My decision is voluntary, and I understand that I may terminate these services at any time. I also understand that during the course of this program I may need to discuss material of an upsetting nature in order to resolve my problems. Further, I understand it cannot be guaranteed that I will feel better after completion of treatment.