Personal History Questionnaire CONTACT INFORMATION First Name * Last Name * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Mobile Phone Number * (###) ### #### Daytime Phone Number (###) ### #### Evening Phone Number (###) ### #### Date of Birth * MM DD YYYY Gender * Female Male Identify as: Prefer not to say Who referred you? Internet Search Doctor Family Member or Friend Psychology Today Other DESCRIPTION OF PRESENTING PROBLEM(S) Describe the services you have requested: How severe is the problem/issue(s)? * Incapacitating Very Serious Serious Moderate Mild When did the problem(s) begin? * Provide dates if possible. What are your goals for attending counselling at this time? * EMOTIONAL HEALTH Have you experienced any other emotional stressors over the past five years? * No Yes How would you rate your current ability to cope? * Very Negative Somewhat Negative Neutral or N/A Somewhat Positive Very Positive How would you rate your current ability to cope? * Terrible Poor Fine Great Other How would you rate your current Quality of Life? * Terrible Poor Fine Great Other Please list any current prescription medications and supplements. Do you see a psychiatrist and or have you been diagnosed with any medical or mental health conditions? * No Yes Your personal history has been sent Dr. Grace’s inbox. If you would like a copy of your responses, please email. Please expect a follow up email within two business days.
