Stephanie Cress, RN, LCSW, CTS(Lic#: LCS 20796)

1819 Union StreetSan Francisco, CA94123415.409.2949watercress1 @ aol.com

Name:Date:

Please complete the following confidential questions on pages 1 & 2:

  1. For what concerns do you seek assistance?
  1. How did you decide to seek assistance now?
  1. How have you dealt with your concerns up until now?
  1. Have you ever seen a psychotherapist before?Y N

If yes, please list who, when, and for what concern:

  1. Have you experienced any recent changes, stress, or situations that may have had an impact upon you? If

yes, please briefly describe:

  1. Please list any medications you are taking, including general, over-the-counter & psychiatric medicines:
  1. Do you use alcohol?How much/How often?
  2. Do you smoke cigarettes?How many/How often?
  3. Do you use other substances or drugs (caffeine, etc…)? What kind? How much/How often?
  1. Do you experience any ongoing physical problems? (for example: chronic pain, diabetes, etc…) Y N

If yes, describe type and length of time experienced:

  1. Please list any serious injuries or accidents you have had (for example: head injuries, seizures, etc…):

Name:Page 2

  1. Has anyone in your family ever been diagnosed with a psychiatric illness? Y N

If yes, please note who and which diagnosis:

  1. Have you ever been hospitalized for a mental health or chemical dependency reason?

If so, please list where, your age, & how long:

  1. Have you ever attended an outpatient program for a mental health or chemical dependency reason?

If so, please list where, your age, & how long:

  1. Please check items which may apply to your current situation:

______Headaches______Decreased need for sleep ______Crying a lot

______Dizziness______Excess energy/feeling wired______Fears

______Stomach/bowel trouble______Confusion______Unable to have a good time

______Health problems______Elated/euphoric mood______Nightmares

______Eating problems______Excessive spending______Fears of losing control

______Binge eating______Racing/overflow of thoughts______Recurring unwanted thoughts ______Sleep problems ______Irritable ______Recurring unwanted behaviors

______Weight loss______Impulsive behavior______Always worried

______Weight gain______Grandiose thoughts or plans______Concentration problems

______Loss of appetite______Anger or explosiveness______Financial problems

______Feeling apart from others______Panic attacks______Family conflict

______Low energy______Anxiety______Relationship problems

______Feeling worthless______Memory problems______Thoughts of suicide

______Restlessness______Physical/sexual abuse______Strange experiences

______Feeling depressed______Someone physically harmingyou______Hear things others don’t ______Tremors or tics ______Constant suspicion/mistrust ______Violent/aggressivebehavior ______Thoughts of physically harming someone