The Living Resources Center

Pre-Therapy Questionnaire

*Please answer the following questions:*
Have you had any prior psychotherapy/counseling? If so, when?
Are you currently on any medications? If so, please list and include dosages, if known.
Are you allergic to any medications? If so, which ones?
Do you have a family history of mental illness or substance abuse?
Have you ever attempted suicide, or had a plan to hurt yourself you never carried out?
Do you currently have any thoughts or feelings of wanting to physically harm yourself? If so, do you also have a specific, concrete plan to do so?
Have you ever been diagnosed with an eating disorder (anorexia/bulimia)?
Were you physically abused as a child?
Were you sexually abused as a child, or do you suspect that you might have been?
Describe your current usage of alcohol and/or drugs:
Have you ever been treated for substance abuse or addiction? If so, when?
Do you have any current or past major medical problems? Please describe very briefly.
Do you have (1) current sleep difficulties, or (2) decrease/increase in appetite?
What would you like to see happen as a result of going to a therapist?

From the following table, check the box in front of any of the items that you feel apply to you:

Headaches	Naive	Memory problem
Heart palpitations	Nervous	Unattractive
Sleep problems	Cowardly	Bored
Want to hurt self	Timid	Restless
Drug problems	Can't concentrate	Nightmares
Financial problems	Worthwhile	Life is empty
Incompetent	Regretful	Fatigue
Pushy	Misunderstood	Tense feeling
Shy	Sympathetic	Sex problems
Don't take vacations	Intelligent	Worthless
Confused	Fainting spells	Stupid
Considerate	No appetite	Evil
Deformed	Alcohol problems	Overambitious
Not confident	Depressed	Good person
Can't make decisions	Inadequate	Dizziness
Can't make friends	Horrible thoughts	Attractive
Stomach trouble	Guilty	Lonely
Panicky feelings	Hateful	Unloved
Shaking	Inferiority feelings	Confident
Unable to relax	Home conditions bad	Can't keep a job

Use this space to add any other words, thoughts, feelings that apply to you:

Please fill in the following information:

Full Name (of primary client):
Date of birth:
Address Line 1:(street address)
Address Line 2:(city, state/province, zip/postal code)
Address Line 3:(country / other)
Home Telephone Number:
Work Telephone Number:(optional)
Email Address:(optional)
Social Security Number:
Name and SSN of subscriber to insurance policy/EAP, if using insurance/EAP:
Who referred you to Dr. Hurd?
Preferred method of consultation	Office Visit Phone Consultation E-mail Consultation

Once completed, press the "Send to Dr. Hurd" button below. If you want to start over or simply erase your entries, press the "Clear this Form" button.

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