Confidential Initial Session Form
Each person participating in therapy is asked to complete this secure form.
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Salutation
Mr.
Mrs.
Ms.
Dr.
Today's Date:
*
First Name
*
Last Name
*
Nickname
Please list of names of persons attending therapy with you
Street address
*
City
*
State
*
Zip Code
*
Main Phone (10 digits)
*
Type of phone
Mobile
Work
Home
Other
Is it OK to leave a message at this number?
*
Yes
No
Please indicate if text Messages, related only to scheduling, may be sent to this number.
Yes
No
Other Phone
Type of phone?
Work
Home
Mobile
Other
Is it ok to leave a message at this number?
Yes
No
Please indicate if text Messages, related only to scheduling, may be sent to this number.
Yes
No
Email
*
Email is not always a secure way to communicate. Please indicate if you would like email encrypted.
*
No, Normal Email
Yes, Encrypted email
No email please
Would you like to receive resources from Fuller Life about relational, mental and emotional health?
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Yes, I do want resources from Fuller Life
No, I do not want to receive resources from Fuller Life
Would you like an email appointment reminders? (Only 1 email per family. Emails are not encrypted)
No
Yes
Type of therapy
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Individual therapy
Couples therapy
Family therapy
Therapy for child
Therapy for adolescent
Partner with Fuller Life
Intensive couples therapy
Unsure
Other
Names and Ages of all who live in the home:
Date of birth
*
Please type if calendar feature does not work. (Format: xx/xx/19xx)
Sexual Orientation
Heterosexual
Homosexual
Bisexual
Unknown
Other
Gender
*
Male
Female
Transgender
Marital Status
*
Cohabitating
Divorced
Married
Separated
Single
Widowed
Other
If married or cohabitating, name of partner/spouse:
If Married, Date of Anniversary
Please type in date (XX/XX/XXXX) if calendar does not work
Ethnicity
African American
Asian
Caucasian
Hispanic
Middle Eastern
Mixed Race
Other
Unknown
Religion
Catholicism
Christianity
Judaism
Islam
Buddhism
Hinduism
Native American
Athiest
Unknown
Other
Would you like spirituality to be part of therapy?
Yes
No
Unsure
Please describe your level of activity with the above religious/spiritual practice.
Active
Somewhat Active
Inactive
N/A
Highest level of education
Preschool
Elementary
Middle school
High School
High School Graduate
Some College
Para-professional Degree
Associates Degree
College Graduate
Masters Degree
Professional degree or PhD
Unknown
N/A
Other
Employer
Occupation or Job Title
How did you hear about Fuller LIfe?
AAMFT
Amy Fuller website
Facebook
Family member
Former Client
Friend
Fuller life website
Google Ad
Google Search
Houston Marriage counselor website
Other professional
Pastor
Physician
Psychology Today
Scoopit
Twitter
Website
Yelp
Other
What are your reasons for seeking therapy?
*
Please describe any previous counseling (Type of treatment, length,name of professional and outcome)
Please check one primary concern or symptom below:
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Aggressive Behaviors
Alcohol or drug use or abuse
Anger, Stress, or Anxiety
Depression
Divorce or sepearation
Domestic Violence
Family Problems
Financial Problems
Grief, Loss or Trauma
Health Problems
Insomnia
Infidelity
Intimacy Issues
Legal problems
Marital Problems
Mental Health Concern
Pain Management
Parenting concerns
Physical Abuse
Quick mood changes
Pre-marital Counseling
Problems at work
Problems at school
Sexual Abuse
Sexual Problems
Social difficulty
Suicidal thoughts
Trouble with eating or weight
Other
Please select any symtoms you have experienced in the last 2 weeks:
Aggressive Behaviors
Alcohol Use or Abuse
Anger, Stress or Anxiety
Divorce or Separation
Depression
Domestic Violence
Family Problems
Financial Problems
Grief, Loss or Trauma
Health Problems
Infidelity
Insomnia
Legal Problems
Marital Problems
Mental health concern
Pain Management
Parenting Concerns
Physical Abuse
Pre-marital Counseling
Problems at Work
Problems at School
Sexual Abuse
Sexual Problems
Intimacy Issues
Social Difficulty
Suicidal Thoughts
Trouble with eating or weight
Trouble Communicating
Lack of Sex Drive
Anger Problems
Frustration
Trouble Sleeping
Feel Guilty
Excessive Worry
Stress
Extreme Fear
Panic Attacks
Spiritual Issues
Feel Lonely
Withdrawn from Others
Feeling Sad or Down
Trouble Concentrating
Feel Hopeless
Cry Often
Low Self-Esteem
Loss of Appetite
Weight Changes
Feeling Tired
Low Energy
Low Motivation
Quick Mood Changes
Lying or Dishonesty
Nightmares
Upset Stomach
Severe Pain
Headaches
Sweating
Trouble Breathing
Can't Stop Thinking
Disordered Eating
Binging
Restless/Can't Sit Still
Impulsive
Hear Strange Things
See Strange Things
Thoughts of Death
Others Out to Get Me
Wanting to Hurt Others
Wanting to Hurt Myself
Smoke Cigarettes
Drug Use or Abuse
Other
Pleas comment on above concerns or symptoms
Please check any that are a part of your history.
alcohol
addictions
cruelty to animals
difficulty to animals
medical problems
military history
physical aggression
previous hospitalizations
smoke
trauma
trouble with law
trouble with school
violence to property
weight changes
Please share relevant information about your medical, familial, mental, or employment history.
Name of primary physician
Primary Physician Phone
Please list all current medications, dosage, reason for medication and prescribing physician
Please provide a contact in the case of emergency
*
Please provide a phone number for the emergency contact
Please describe your relationship with the emergency contact
Please provide the name of the party responsible for payment for therapy services
*
Please provide a phone contact for the party responsible for payment of therapy services
*
Please describe your relationship to the responsible party
*
Self
Parent
Spouse
friend
Other
If you would like to use your insurance or find out what your benefits, list insurance name:
Insurance ID number
Insurance company phone number for behavioral health or customer service
List the zip code for the insurance claim address
Please provide any additional comments
Please select the name of your therapist:
Amy Fuller PhD, LMFT-S, LPC-S
Please type your name as an electronic signature. Additional Signatures will be required in person.
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