Questionnaire

Name

Date

What do you prefer to be called?

Address

City

State

Zip Code

Birth Date

Telephone

Marital Status

Single Divorced Married Widowed Other

Gender Identification

Are you a spiritual person?(select all that apply)

Yes No Unsure I believe in a higher power This is the only life I live

Occupation

Name of Spouse/Significant Other/NA

Children's Names & Ages

Emergency Contact Name

Emergency Telephone

How did you hear of FARE/ Who referred you?

Though you are under no obligation to answer medical questions and they will not be disclosed unless required by law, it is helpful for us to know if you have ever been treated for:

Diabetes Heart Condition Cancer Epilepsy Aches/Pains Allergies/Asthma Phobias** Anxiety** Clinical Depression** OCD* NPD* Bipolar Disorder* Borderline Personality Disorder* Schizo-Affective type Disorders*

Other persistent problems or conditions

In the past year have you/are you currently seeing a doctor for medical and/or emotional reasons?

Yes No

List medications/purpose

Do you drink alcohol?

No Yes, in moderation Yes, more than I should

Do you abuse drugs/medications?

Yes No

Have any of these events occurred in the past year, are occurring, or will in the next 6 months

Deaths Job lost/change Move Marriage Divorce Child leave home Birth Accident Miscarriage Abortion Pet death Other

Explain

Are you experiencing any excessive:

Anger Guilt Sadness Fear Loneliness Boredom Inadequacy Stress Frustration Sympathy Other

What issue are you interested in resolving?

How long have you been affected by this issue?

Why are you addressing this now?

In what ways have you tried to address this before?

How has this impacted your life in the past? (missed events, money, relationships, etc)

How much time and money have you invested in attempting to resolve this issue?

What people/places/events/things have gotten or could get in the way of your success in addressing this issue?

How would life be different if this was solved?

What if nothing changes?

On a scale of 1-10 how committed are you to resolve this problem?

1 2 3 4 5 6 7 8 9 10

Why do you think I should work with you?

What else should I know?

List at least five specific positive benefits that you would like to gain from working together:

Confirm Welcome Letter

Yes, I have read the Welcome letter

Understand Bill of Rights

Yes, I have read the Bill of Rights, or if I am a parent, Bill of Rights for Minors.

Confirmation of Agreement

Yes, I have read and agree to the following:

Please take time to thoughtfully consider the last question: 5 specific positive benefits you wish to focus on during your sessions. Note how they could change your life if they were to be accomplished. This is an extremely important part of this paperwork. If you have problems with it, don't worry, we will spend time with you in developing this section.

We have a 48 hour cancellation policy for all appointments. You will not be charged if you cancel or reschedule your appointment before the required two business days’ (Monday – Friday) notice. For example, if the appointment is on Monday, in order not to be charged for an appointment, our office must be notified of the change no later than Thursday during office hours.

Clients who make cancellations within the 2 working day period, miss appointments or reschedule on the same day as the appointment will be charged for the time scheduled for that day, because we will be unable to utilize your reserved time slot to schedule in another client upon such short notice. Please know that we make very few exceptions to this policy.

We ask that you arrive 5 minutes before your appointed time online to test your microphone and connection. If you are late, you will forfeit that amount of time for your visit. Occasionally we may run late with a client. You will always receive your full, allotted time.

By submitting this form, you acknowledge and agree that the information contained here is complete and accurate and that you understand our policies.

Thank you, and we look forward to working with you!
** Work only with referral and release
* Do not work with clients with this diagnosis
May need referral for all others

2520 St Rose Parkway #203-F

Henderson, NV 89074

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Call 612-839-2295