*Name
Address
City
State
Zip
Home Phone
Cell Phone
Work Phone
*Email
Twitter/Facebook
Weight
Height
Date of Birth
Prefered Contact By
Best Time To Call

How many sessions do you think you will need?
What is your primary reason for attending sessions?
What would you like to accomplish?
Primary Care Physician (Name)
Phone Number
List all medications you are currently taking (Name and amount)
Educational Status
Marital Status
Number of children
Ages of Children
Father's Height
Father's Weight
Father's Profession
Mother's Height
Mother's Weight
Mother's Profession

Let us know which are the most problematic and the least problematic issues you have trouble with. This helps us determine which issues are most urgent for you.

Marriage	select level Least problematic Problematic Quite Problematic Most Problematic
Divorce	select level Least problematic Problematic Quite Problematic Most Problematic
Dating	select level Least problematic Problematic Quite Problematic Most Problematic
Children	select level Least problematic Problematic Quite Problematic Most Problematic
Addictions	select level Least problematic Problematic Quite Problematic Most Problematic
Weight	select level Least problematic Problematic Quite Problematic Most Problematic
Smoking	select level Least problematic Problematic Quite Problematic Most Problematic
Sexual Issues	select level Least problematic Problematic Quite Problematic Most Problematic
Fear	select level Least problematic Problematic Quite Problematic Most Problematic
Relationships	select level Least problematic Problematic Quite Problematic Most Problematic
Stress	select level Least problematic Problematic Quite Problematic Most Problematic
Phobias	select level Least problematic A little Problematic Problematic Quite Problematic Most Problematic
Eating Disorder	select level Least problematic Problematic Quite Problematic Most Problematic
Past Hurts	select level Least problematic Problematic Quite Problematic Most Problematic
Parents	select level Least problematic Problematic Quite Problematic Most Problematic

Alcohol	select level Least problematic Problematic Quite Problematic Most Problematic
Drugs	select level Least problematic Problematic Quite Problematic Most Problematic
Money	select level Least problematic Problematic Quite Problematic Most Problematic
Mood Swings	select level Least problematic Problematic Quite Problematic Most Problematic
Loneliness	select level Least problematic Problematic Quite Problematic Most Problematic
Sleeping	select level Least problematic Problematic Quite Problematic Most Problematic
Shyness	select level Least problematic Problematic Quite Problematic Most Problematic
Work	select level Least problematic Problematic Quite Problematic Most Problematic
Communication	select level Least problematic Problematic Quite Problematic Most Problematic
In-Laws	select level Least problematic Problematic Quite Problematic Most Problematic
Self-Esteem	select level Least problematic Problematic Quite Problematic Most Problematic
Intimacy	select level Least problematic Problematic Quite Problematic Most Problematic
Aging	select level Least problematic Problematic Quite Problematic Most Problematic
Codependency	select level Least problematic Problematic Quite Problematic Most Problematic

Where did you hear about us?
How did you hear about us?
Referred by (Name)
Relationship to referrer

 

****Supplements- We strongly recommend that when you purchase any of our vitamins and supplement pills you contact your physician and consult them for their usage approval.
****A note on phone appointments- We also offer phone appointments, since we treat people all over the world. Phone sessions are a normal part of our business. Sessions over the phone will be billed at the normal rate. All phone sessions are regular sessions, therefore the cancellation policy (see below) applies. Please cancel your appointment within 24-hours.
****Regardless of how you choose to pay for your sessions, you must enter a credit card number below for our records. We keep strict confidentiality on all information you provide us, and we guarantee your complete security. The card you provide will be charged for phone-sessions, and/or in the event of a tardy cancellation or "no-show". Please refer to our Cancellation Policy below.
Cancellation Policy: If you need to cancel or reschedule your appointment, you must let us know at least 24 hours in advance. If notice of cancellation is given less than 24 hours before the scheduled time of your appointment, you will be charged the full session fee. If you have an appointment on a Monday, you need to cancel your appointment by the Friday before or you will be held accountable.
	I understand that my therapy is a commitment of time and finances. I agree that unless I give a 24-hour notice before cancelling I will be charged the full fee for the session