Registration — Dr. Beth Gouse

Email Address

Gender

Relationship Status

Emergency Contact

Relationship

Email

Referral Source

Present Reason For Seeking Help

Please briefly describe your current problem or symptoms

How long have you been experiencing this problem or symptoms?

Were there any precipitating events (e.g., loss of a family member or friend, major health issue, job loss, etc.)?

How have you tried to cope with this problem or manage your symptoms?

Background Information

Education

High school graduate?

Yes/No (if yes, year attained)

College graduate?

Yes/No (if yes, year attained)

Graduate degree?

Yes/No (if yes, degree and year attained

Please describe any additional information about your education history which you think would be useful:

Employment Information

Please describe any additional information about your occupational history which you think would be useful

If yes, please provide dates of service and branch of service

Family

Mother

Current age or date deceased

Health status or cause of death if deceased

Occupation

History of mental health or substance use issues? If so, please describe

Father

Current age or date deceased

Health status or cause of death if deceased

Occupation

History of mental health or substance use issues? If so, please describe

Siblings

Current age or date deceased

Health status or cause of death if deceased

Occupation

History of mental health or substance use issues? If so, please describe

Besides individuals listed above, were there other adults (e.g., grandparents, etc.) living with you during your childhood? If yes, please describe

Please provide information about the individuals with whom you currently reside below:

Name Relationship (i.e., partner, spouse, child) Age Occupation (i.e, employed, student) Hx of mental health or substance use issues? If so, please describe

Medical/Psychological History

Do you have any current or past medical issues? If so, please describe

Do you exercise? If yes, how often?

Do you smoke? If so, how often and for how long?

Do you drink alcohol? If yes, how often and how much?

Do you use non-prescribed drugs? If so, how often, how much, and type?

If you use alcohol or non-prescription drugs:

Have you felt the need to cut down on your use? Yes/No. If yes, please describe

Does your use affect your job or relationships? Yes/No. If yes, please describe

Has anyone expressed concern to you about your use? Yes/No. If yes, please describe

Do you have allergies? If yes, please describe

Do you have a history of head trauma? If yes, please describe

Are you currently taking any medications prescribed by a doctor? Yes / No. If yes, please provide information below:

Medication Dosage Reason prescribed Length of time taken or approximate date began taking

Have you sought mental health treatment in the past or have you experienced any mental health issues in the past? If so, please provide information about prior or current treatment, including any medications or hospitalization below:

Ex: Depression Anxiety Eating Disorders Suicidal thoughts/Behavior Trauma/Abuse Schizophrenia Substance use (please specify) Attention-deficit hyperactivity disorder Homicidal thoughts/Behavior Other (please specify)

Additional Question

Are any family members/friends a source of support for you? Yes/No. If yes, please specify

Do you have any recreational or leisure activities in which you routinely participate? Yes/No. If yes, please specify

Do you currently have any legal issues or concerns?

If yes, please explain.