Whole Wellness Counseling
Marci E. Warren M.Ed., CRC, LPC, LPC-S
Hymeadow Offices
12335 Hymeadow Dr., Ste. 300
Austin, TX 78750
512-663-8447
Personal Information
*Please complete before first appointment or print and carry to first appointment for completion during session.
Name
Gender
Date of birth
Address
Zip
Phone (home)
Date
F
M
Age
City:
(work)
State
ext
Email: _______________________________________
Insurance Information:
______________________________________________________________
______________________________________________________________
Primary reason(s) for seeking services, please briefly explain:
Anger management
__________________________
__Anxiety ____________________________________________________
__PTSD/Trauma________________________________________________
__Coping ____________________________________________________
__Depression _________________________________________________
Eating disorder______________________________________________
__Fear/phobias ________________________________________________
__Life Coaching ________________________________________________
__Mental confusion _____________________________________________
__Relationship issues/Marital therapy
______________________________________________________________
______________________________________________________________
Sexual concerns _____________________________________________
Sleeping problems
_________________________________________
__Addictive behaviors _________________________________________
__Alcohol/drugs ________________________________________________
Other wellness concerns:
______________________________________________________________
______________________________________________________________
______________________________________________________________
Social Relationships
Check how you generally get along with other people: (check all that apply)
Affectionate
Aggressive
Avoidant
Fight/argue often
Follower
Friendly
Leader
Outgoing
Shy/withdrawn
Submissive
Other (specify):
Spiritual/Religious
How important to you are spiritual matters? Not
Little___ Moderate___
Very Much ___
Are you affiliated with a spiritual or religious group?
_____Yes ____ No
If Yes, describe:
___________________________________________________
Legal
Current Status
Are you involved in any active cases (traffic, civil, criminal)?
______Yes _____ No
If Yes, please describe and indicate the court and hearing/trial dates and
charges:
Education
Fill in all that apply:
Years of education:
Currently enrolled in school? ____Yes
High school grad/GED
Vocational
College
Other:
__ No
Employment
Are you employed/Where:_________________________________________
______________________________________________________________
For how long: __________________________________________________
Medical History
List any recent health or physical changes:
__________________________________
Family history of medical or psychological problems:
______________________________________
Chemical Use History
Alcohol
Illegal Drugs
Caffeine
Nicotine
Over the counter
Prescription drugs
Other drugs
Substance of preference
1.
2.
3.
4.
Please check behaviors and symptoms that occur to you more often than you
would like them to take place:
Aggression
Elevated mood
Phobias/fears
Alcohol dependence
Fatigue
Recurring thoughts
Anger
Gambling
Sexual addiction
Antisocial behavior
Hallucinations
Sexual difficulties
Anxiety
Heart palpitations
Sick often
Avoiding people
High blood pressure
Sleep problems
Chest pain
Hopelessness
Speech problems
Cyber addiction
Impulsivity
Suicidal thoughts
Depression
Irritability
Disorganization
Disorientation
Judgment errors
Trembling
Distractibility
Loneliness
Withdrawing
Dizziness
Memory impairment
Worrying
Drug dependence
Mood shifts
Other (specify):
Eating disorder
Panic attacks
Briefly discuss how the above symptoms impair your ability to function
effectively:
What are your goals for therapy? What do you hope to gain from this process?
________________________________________
________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
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