GENERAL REGISTRATION FORM
Stress • Chronic Pain • Excessive Drinking • Drug Abuse
Phobias • Nail Biting • HairPulling • Depression • Memory Improvement
Your success is our #1 priority. Assist us in helping you to attain that success by filling out this questionnaire as completely as possible.
This information will be kept
strictly confidential
.
Date:
Name:
Marital Status:
Address:
City/State/Zip:
DOB:
Age:
Occupation:
Phones/Contact:
Home:
Work:
Cell:
Email:
Method of Payment:
Cash
Check
VISA
MasterCard
Driver's License #
(if paying by check):
State:
Have you ever seen a
(check all that apply)
Psychologist
Counselor
If yes, please give their name(s):
Where did you hear about us?
(check all that apply)
Newspaper
TV
Yellow Pages
Radio
Physician Referral
Web Site
Other
(specify)
How were you referred to Dr. Smith?
Who is your physician and what is their specialty?
Physician's office location
(City/State/Zip)
:
Do you object to us contacting him or her about your success?
Yes
No
Would imagining any of the following during a session make you feel uncomfortable?
Escalators
Elevators
Water
The Ocean
The Beach
Space
Floating
Do you have any of these issues for which office or phone counseling may be utilized?
(Check all that apply)
Smoking
Weight Loss
Pain Management
Depression/Anxiety
Anger
Excessive Drinking
Nail Biting
Stress
Poor Sleep
Phobias/Fears
Substance Abuse
Sexual Issues
Motivation
Breathing
Describe the problem(s) you are presenting with:
How long have you experienced this problem?
Have you ever gotten relief from this issue?
Yes
No
If yes, how did you accomplish it?
For Excessive Drinking Only
What type of alcohol do you consume?
How much alcohol do you consume each day?
List three places or situations in which you drink the most:
1.
2.
3.
List three reasons you want to stop drinking:
1.
2.
3.
What methods have you used to stop drinking before?
Circle your strongest desire to stop drinking, with 10 equaling the strongest.
1
2
3
4
5
6
7
8
9
10
Please submit and bring in this form to your consultation.