General Registration Information

General Registration Information

Name: ______Date:______

Date of Birth/Age: ______

Address: ______

Home Phone: ______Cell: ______Work: ______

Is it OK to leave a message at these numbers? Home: Y N Cell: Y N Work: Y N

Can information be emailed to you? ______Yes ______No

Initials Initials

(By selecting “Yes” you are giving your consent to email information that may be confidential. You understand that Privacy through email cannot be guaranteed.)

If Yes, please provide your email address: ______

Can information be text messaged to you? ______Yes ______No

Initials Initials

(By selecting “Yes” you are giving your consent to text message information that may be confidential. You understand that Privacy through text message cannot be guaranteed.)

Employer/School______

Occupation or Grade Level______

Emergency Contact______Phone______

Address:______Relationship______

How did you hear about Chrysalis Center?______

Relationship Status:

_____Married _____Single _____Widowed

_____Separated _____Living Together _____Other (please specify)

_____Divorced _____Committed Partnership

If married or in a committed partnership, how many years have you been together?______

Spouse/Partner Name:______

Household Members:

NameRelationship to you AgeOccupation

______

______

______

Ethnicity (Please check one or more):

_____Caucasian _____Asian _____African American _____Hispanic or Latino

_____Native American or Pacific Islander _____Other (please specify)______

Religious Affiliation:______

Mental Health Information

Please briefly describe the reason you are seeking therapy at this time:______

What do you hope to accomplish in our work together (2-3 goals)?______

______

Please check all that apply currently or within the last year:

_____Behavioral Issues _____School/Work Issues _____Relationship Issues _____Marriage Issues

_____Sexual Issues _____Anxiety Issues _____Depression _____Hallucinations

_____Panic _____Phobia _____Irritability _____Nightmares

_____Unhappiness _____Loneliness _____Bedwetting _____Fears

_____Guilt _____Hopelessness _____Restlessness _____Health Issues

_____Trauma/Crisis Event _____Death of loved one _____Substance Abuse _____Confusion

_____Self Esteem/Self Growth Issues

Have you ever been a victim of Abuse? Yes_____ No_____

If yes, was the abuse as a Child_____, or as an Adult_____

Have you experienced:

 Appetite Issues: _____Increased, _____Decreased, Length of time______

 Weight Issues: _____Gain, _____Loss

 Sleep Disturbance: _____Increased, _____Decreased, Average hours of sleep______

 Energy Level: _____Increased, _____Decreased, Length of time______

 Unable to care for self: Length of time______

 Other (please describe)______

______

Have you ever had thoughts of suicide? YES NO Most Recent:______

Have you ever attempted suicide? YES NO Dates:______

Are you currently having suicidal thoughts? YES NO Please explain:______

______

Have you ever had thoughts of homicide? YES NO Most Recent:______

Have you ever attempted to injure another person? YES NO Dates:______

Are you currently having homicidal thoughts? YES NO Please explain:______

______

If you have had previous mental health treatment, please list dates, practitioner, reason for treatment and your overall experience in therapy.______

______

Please describe your strengths, interests, and talents:______

______

Please describe any past or current significant drug or alcohol use.______

______

Please describe any past or current experiences of abuse or domestic violence.______

______

Please describe any legal problems, including charges.______

______

Please share any other information that you would like for me to know or that you find interesting about yourself. ______

______

Insurance Information (Please provide a copy of your insurance card)

Insured’s Name______DOB: ______

Insurance Company: ______Phone: ______

Address: ______

Group Number:______Personal ID: ______

I hereby consent and authorize to have this therapist make any and all insurance claims on my/our behalf. I understand that by submitting claims to insurance confidential information must be reported. I understand that all questions concerning insurance reimbursement and financial responsibility are to be discussed with my therapist.

Signature: ______Date:______

Chrysalis Center for Family Growth, LLC

1200 S College Ave. L7, Fort Collins, CO 80524  305 W South 1st Street, Johnstown, CO 80534

970-231-2681  Fax: 970-587-1160 