Schedule A Consult ✺ Schedule A Consult ✺ Schedule A Consult ✺ New Client Questionnaire Name * First Name Last Name Preferred Pronouns * Email * Phone (###) ### #### Date of Birth * MM DD YYYY What type of therapy experience are you seeking? * In-Person Virtual How did you hear about me? * What is bringing you to therapy at this time? What are you hoping to address or explore? Please be as detailed as possible. * What goals do you have for therapy? Please list three things you are needing/wanting at this time. * Have you worked with a therapist before? If so, when did you work with them and what was your experience like? * Do you take any medications for your mental health? If so, what medications & what do you take them for? * Have you previously received any diagnoses? If so, what are they? * Which of the following have you experienced? Please be aware that amongst other presenting mental health concerns, I do not specialize in or see clients who are currently experiencing items 1 - 6. If you check "I am currently experiencing" for items 1 - 6, I will not be responding to your inquiry, as I will not be able to provide you with quality care for your needs. 1. Suicidal ideation (thoughts, plans, or attempts to kill myself) * I have experienced in the past I am currently experiencing I have not experienced 2. Homicidal ideation (thoughts, plans, or attempts to kill someone else) * I have experienced in the past I am currently experiencing I have not experienced 3. Self-harm (intentionally cause physical harm to oneself) * I have experienced in the past I am currently experiencing I have not experienced 4. Substance abuse issues * I have experienced in the past I am currently experiencing I have not experienced 5. Eating disorder or disordered eating behaviors (restrict food intake, excessively exercise, self-induced vomiting, hide food, frequently eat past the feeling of fullness, etc.) * I have experienced in the past I am currently experiencing I have not experienced 6. Hear voices inside my head that others cannot hear and/or see things that are not there * I have experienced in the past I am currently experiencing I have not experienced 7. Abuse (physical, sexual, emotional, verbal, financial) * I have experienced in the past I am currently experiencing I have not experienced 8. Panic attacks or anxiety attacks * I have experienced in the past I am currently experiencing I have not experienced How frequently are you wanting to engage in therapy sessions. * Weekly Biweekly 9. Periods of daily sadness lasting more than two weeks * I have experienced in the past I am currently experiencing I have not experienced I am not the therapist for you if: * - You do not want to focus on your emotions. - You want me to give you answers or advice. - You want me to tell you what we will be processing/exploring each session. - You want a list of tools or a quick fix for your presenting issues. If my approach doesn't fit with you, that's okay! There are so many different approaches & I encourage you to find a therapist that best fits with your needs. Please indicate below whether you are okay with each aspect of my approach I am good with this. I have some questions. Preferred method of payment for sessions * If you using insurance, please send your Insurance ID# as well. Out-of-Network OHP/ Care Oregon Providence Health Plan Pacific Source CCO What else would you like me to know? Do you have any questions for me? * Thank you! We’ll be in touch shortly. 503-512-9846Alle@StormsStillness.com328 NE FAiling STPortland, OR 97212 Verified provider with
