Personal Growth

Better Quality of Life

Reduced Stress

Adult Registration Form

  • Date Format: MM slash DD slash YYYY
  • How distressing is this issue for you (on a scale of 1-10, with 1=not Please indicate how this has affected your ability to function: distressing, 10=most distressing):
  • Symptoms and Issues (Check all that apply)

  • Background Information

  • Date Format: MM slash DD slash YYYY
  • Spouse/Significant Other Information:
  • Date Format: MM slash DD slash YYYY
  • NameAgeWedding/DivorceLength of RelationshipChildren with This Person 
  • NameAgeJob/RetiredPhysical/Emotional Health History 
  • NameAgeJob/RetiredPhysical/Emotional Health History 
  • Indicate which parent he/she is married to and the year they were married
  • NameAgeJob/GradePhysical/Emotional Health History 
  • Safety

  • Are you currently, or have you in the past, experienced:
  • Educational History

  • NameDates AttendedDegree/CertificateMajor/Area of Study 
  • Psychological/Mental Health History

  • Clinic or TherapistDates of ServicesReason 
  • Hospital/ClinicDates of ServicesReason 
  • Medical History

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Name of Medication and DosagePurpose of MedicationLength of Use 
  • Do you currently, or have you in the past, had a history of:
  • Social History

  • Employment History

  • PositionDutiesDate (from-to) 
  • Military History

  • Branch of the MilitaryPosition/RankDates of Service (from-to) 
  • Religion Culture Beliefs

  • On a scale of 1-5 (with 1=least important, 5= most important), how important is your
    Religious involvementSpiritual involvement 
  • Substance Use

  • Please identify current and historic substance use:
  • Please fill out the information below. Substance type examples would be Alcohol,Tobacco,Illicit Drugs,Misuse of Rx meds,Caffeine
    SubstanceTypeQuantityFrequencyDates 
  • Please answer the following:
  • Name of Program/ProviderInpatient/OutpatientDates (from-to) 
  • Client Expectations