Confidential Health Information

Confidential Health Information

First name

Last name

Phone

Birthday

Month

Day

Year

Address

Occupation

Employer

1. Are you currently in or have you had any prior therapy or psychological counseling?

Yes

2. Have you been hospitalized for mental health reasons?

Yes

3. Are you currently taking or have you ever taken medication for psychosis, schizophrenia, or bipolar disorder?

Yes

4. Have you ever been incapacitated by severe depression, anxiety, or other mental disturbance?

Yes

5. Have you ever harmed or threatened to harm yourself or become violent toward others?

Yes

If yes, was there a direct suicide attempt? When? When was the last time you contemplated or fantasized about suicide? Did you seek help? Please explain.

6. Within the last 12 months have you been dependent on alcohol, marijuana, cocaine, or any similar non-prescribed drugs?

Yes

If yes, please explain.

7. Describe any events in your life that resulted in significant trauma from any kind of abuse (i.e., physical, emotional, mental, verbal, sexual, or spiritual).

8. Describe any events in your life that resulted in significant trauma from the loss of a loved one or other significant loss.

Emergency Contact

Name and Relationship

Phone Number

I hereby acknowledge and attest that I have thoroughly and carefully read the information contained in the welcome email, that I understand it, that I have answered all the questions fully and truthfully, and that I take full responsibility for my participation in the Possibilities for Life Workshop.

Printed Name

Date

Month

Day

Year

Confidential Health Information

Birthday

Month

Day

Year

1. Are you currently in or have you had any prior therapy or psychological counseling?

Yes

2. Have you been hospitalized for mental health reasons?

Yes

3. Are you currently taking or have you ever taken medication for psychosis, schizophrenia, or bipolar disorder?

Yes

4. Have you ever been incapacitated by severe depression, anxiety, or other mental disturbance?

Yes

5. Have you ever harmed or threatened to harm yourself or become violent toward others?

Yes

If yes, was there a direct suicide attempt? When? When was the last time you contemplated or fantasized about suicide? Did you seek help? Please explain.

6. Within the last 12 months have you been dependent on alcohol, marijuana, cocaine, or any similar non-prescribed drugs?

Yes

If yes, please explain.

7. Describe any events in your life that resulted in significant trauma from any kind of abuse (i.e., physical, emotional, mental, verbal, sexual, or spiritual).

8. Describe any events in your life that resulted in significant trauma from the loss of a loved one or other significant loss.

Emergency Contact

Name and Relationship