Dr. Jeffrey Title

TODAY’S DATE: _________________

 

YOUR INFORMATION

Your Name:                                                         Nationality:                                                      Religion:                                                              

Your Age:                                                           Address:

City:                                                                                State:                                     Zip:

Home Phone:                                                   Business Phone:

Mobile #:                                                    Email Address:

Other Additional Phone #(s):       

Profession:                   

Number Years Married to Current Spouse (or years in current relationship):

Children’s Names and ages:        

Previous Marriage(s) & length of Marriage(s):

 

YOUR FAMILY OF ORIGIN

(If you were raised by more than one family please duplicate this section for each family)

 

Mother’s Name:                                                Nationality:                                                      Religion:

Father’s Name                                                Nationality:                                                      Religion:

Mother’s Age:                                    Mother’s Location:

Father’s Age:                                    Father’s Location:

Mother’s Health:

Father’s Health:

Mother’s Profession:

Father’s Profession:

 

Write 3 positive adjectives to describe your Mother:                         Write 3 negative adjectives to describe your Mother:

(1)    _________________________________      _________________________________________

(2)    _________________________________      _________________________________________

(3)    _________________________________      _________________________________________

 

Write 3 positive adjectives to describe your Father:                           Write 3 negative adjectives to describe your Father:

 

(1)    _________________________________      _________________________________________

(2)   _________________________________            _________________________________________

(3)   _________________________________            _________________________________________

 

 

 

 

BROTHERS AND SISTERS (please indicate step relationships)

NAME                   AGE              EDUCATION         JOB                       MARRIED?                           CHILDREN

                                                                                               

 

 

 

 

 

 

 

 

NAME                   AGE              EDUCATION         JOB                       MARRIED?                           CHILDREN

                                                                                               

 

 

 

 

 

 

Please provide a list of therapists you have seen starting with current therapists including your primary care health provider.  For each, note their role and whether Dr. Title has permission to contact him or her if need be.

 

 

 

 

 

 

 

 

Dr. Title may communicate with the health providers listed above regarding my current and past health and therapy treatment.

Signed:

Dated:

 

 

CURRENT PROBLEM/ISSUES     - Please provide description of current problems and issues to be addressed:

 

 

 

 

 

 

 

 

When you are really stressed out, give a description of you at your worst.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If you are having relationship issues (dating/spouse, work, friendship, family) please reply to this:

 When the person you are having issues with is really stressed out, give a description of them at their worst.

 

 

 

 

 

 

 

HEALTH CHECKLIST - Check all that apply to each family member and yourself

 

                                                 YOU                 SPOUSE/S.O.      CHILD/CHILDREN             BRIEFLY EXPLAIN

 

ANGER:

 

ANXIETY:

 

DEPRESSION:

 

DRINKING:

 

SUBSTANCE ABUSE:

 

WORKAHOLISM:

 

FOOD ADDICTION:

 

SPENDING/GAMBLING:

 

SEX ADDICTION:

 

PHYSICAL HEALTH:

 

ADDITIONAL INFORMATION

Please describe what you see to be the problems and any other issues you would like to address.   What outcome you would like to have from the counseling sessions?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EMAIL TO: drjeffreytitle@gmail.com