Therapy & Tattoos, llc - Request for Therapy Questionaire

TherapyandTattoosScheduling@therapysecure.com

What brings you to therapy at this time? Is there something specific, such as a particular event? Be as detailed as you can.

Please check here if this request is for an Emotional Support Animal Letter ONLY

Please check here if you are interested in therapy AND an ESA

What are your goals for therapy?

Have you seen a mental health professional before?

Yes

Yes, but I was under 18

Is there a history of mental illness in your family?

Yes - Immediate Family

Yes - Extended Family

Unsure

Who is your Primary Care Physician? Please include type of doctor, name, location and phone number.

Any major medical conditions your therapist should be aware of?

Yes

Other Medical Concern - Specify

Please list the medications you are taking and for what reasons.

Describe your current living situation.

Are you in a relationship? If so, please describe the nature of the relationship and how long that you have been together. Any safety concerns?

Highest level of education?

Current occupation?

Do you drink alcohol?

Yes

Use recreational drugs?

Yes

Occasionally

Do you have suicidal thoughts?

Yes

Have you attempted suicide?

Yes

If yes, have you ever made a plan or attempted to follow through with those thoughts?

Do you have thoughts/urges to harm others?

Yes

If yes, have you ever made a plan or attempted to follow through with those thoughts?

Have you ever been hospitalized for a psychiatric concern? If so, when and where.

Was there a certain session frequency for therapy you were hoping for?

What Insurance do you have? What State (Washington or Wisconsin)

I understand if I am using insurance for costs of care, it will be verified prior to scheduling an intake:

I understand I am not using insurance

Anything else you would like us to know?

First and Last Name

Your Email address

Birth Gender / Identified Gender

Best Contact Phone Number

Date

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