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The Willow Tree Holistic Mental Health
Street Address
Tigard, OR
760-288-1544
760-288-1544
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The Willow Tree Holistic Mental Health
Home
About
A Holistic Approach
Services Provided
contact
New Client Assessment
This form is submitted directly to the therapist. If you have any questions or concerns, please email me at Lgvankirkmft@gmail.com.
Name
*
First Name
Last Name
Email
*
Date of Birth
*
Gender
*
Please provide your biological gender
Male
Female
Physical and mailing address if different from physical
*
Emergency Contact, Name and Phone Number
*
Primary Health Care Provider; Name, Phone Nuumber
*
Primary Language
*
Relationship status
*
Married/Partnered
Divorced/Separated
Widowed
Not in a Relationship
Do you have any children?
*
Yes
No
If yes, please provide 1st names and ages
Current housing situation
*
Please give brief description of where you are living (i.e. by yourself, with your family, roommate, etc..)
Current/Recent Employment
*
If you are not currently working, please give your previous occupation.
Have you ever worked with a therapist?
*
Yes
No
If yes, please give brief description of the experience
Have you ever received a mental health diagnosis?
*
Yes
No
If yes, please describe
Have you ever identified as feeing suicidal or actually attempted suicide?
*
Yes
No
If you answered yes, please give a brief explanation.
Please report any sleep issues
*
Check all that apply
Falling asleep
Staying asleep
Waking too early
Sleeping too much
Frequently napping during the day
None
Please identify any food related issues
*
Check all that apply
Over-eating
Under-eating
Binge-eating
Purging
None
Do you have issues related to sexual function?
*
Yes
No
Not sure
Have you had a full physical exam, including blood work, done in the last 12 months?
*
Yes
No
Have you recently experienced a significant life-trauma (i.e. death of a loved one, loss of a job, loss of a significant relationship, loss of employment, financial stress etc..)?
*
Yes
No
If yes, please give brief description
Have you ever been mentally or emotionally abused?
*
Yes
No
Not sure
Have you ever been physically abused?
*
Yes
No
Not sure
Have you ever been sexually abused?
*
Yes
No
Not sure
Have you ever been involved with religious abuse?
*
Yes
No
Not sure
Have you ever been involved in or exposed to a domestically violent relationship?
*
Yes
No
Not sure
Have you ever had any involvement with Child Protective Services (CPS), either as an adult or a child?
*
Please answer yes if it has involved you as either a child or as an adult.
Yes
No
Have you ever experienced medical trauma?
*
Yes
No
Not sure
Please use this section to provide me with any information you feel is important for me to know prior to our first meeting
How often do you feel depressed?
*
Daily
Weekly
Monthly
Sporadically
Never
How often do you feel anxious?
*
Daily
Weekly
Monthly
Sporadically
Never
Do you struggle to concentrate or stay focused when it is necessary?
*
Yes
No
Not sure
Do you experience racing and/or intrusive thoughts?
*
Yes
No
Not sure
If relevant, please give a brief description of how depression and/or anxiety impacts your life
Do you currently have, or do you have a history of problems with drugs, alcohol that has disrupted your life?
*
Yes
No
Not sure
If yes, please give a brief explanation
Please rate your general life-satisfaction on a rating scale of 1-10, 1 being, "not at all," and 10 being, "fully satisfied."
*
Please give a brief description of what you would like to see be better or different in your life from receiving services.
*
Thank you!