New Client Form

Name:

Email:

Phone:

Please describe your reasons for initiating therapy at this time:

Are you seeking therapy, neurofeedback training, or both?

Please describe what you are hoping to achieve from treatment?

Have you ever utilized the services of a psychiatrist, psychologist, therapist, social worker, or counselor?

Have you ever been seen in a psychiatric emergency room or been hospitalized for psychiatric reasons?

Have you ever heard voices no one else could hear or seen objects or things which others could not see?

Have you ever given in to an aggressive urge or impulse, on more than one occasion, that resulted in serious harm to others or led to the destruction of property?

Have you ever felt that people had something against you, without them necessarily saying so, or that someone or some group may be trying to influence your thoughts or behavior?

Is there anything else you would like me to know?

Symptoms/Issues (Check all that Apply)

NEW CLIENT QUESTIONNAIRE

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CONTACT

4 Carriage Lane

Charleston, SC 29407 - 2020

Phone: (843) 298-0514
Email: Sarah@trueeasewellness.com

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