charonmsw@gmail.com

(734) 765-0869

Therapy Form

Your well-being is our top priority, and this form is the first important step in your journey towards improved mental and emotional health. Please take your time to complete the form with honesty and openness, as the information you provide will help us better understand your unique needs and concerns.

Rest assured that all the information you provide is kept strictly confidential, and our team is committed to maintaining a safe and respectful environment for your process.

Full Name

Email *

Phone *

Adverse Childhood Experience (ACE) Questionnaire

While you were growing up, during your first 18 years of life:

Did a parent or other adult in the household often swear at you, insult you, put you down, or humiliate you? Did they act in a way that made you afraid that you might be physically hurt? *

Yes (1)

No (0)

Did a parent or other adult in the household often push, grab, slap, or throw something at you? Did they ever hit you so hard that you had marks or were injured? *

Yes (1)

No (0)

Did an adult or person at least 5 years older than you ever touch or fondle you or have you touch their body in a sexual way? Did they try to or actually have oral, anal, or vaginal sex with you? *

Yes (1)

No (0)

Did you often feel that no one in your family loved you or thought you were important or special? Did you often feel as your family didn’t look out for each other, feel close to each other, or support each other? *

Yes (1)

No (0)

Did you often feel that you didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you? Did you often feel that your parents were too drunk or high to take care of you or take you to the doctor if you needed it? *

Yes (1)

No (0)

Were your parents ever separated or divorced? *

Yes (1)

No (0)

Was your mother or stepmother often pushed, grabbed, slapped, or had something thrown at her? Was she sometimes or often kicked, bitten, hit with a fist, or hit with something hard? Or ever repeatedly hit over at least a few minutes or threatened with a gun or knife? *

Yes (1)

No (0)

Did you live with anyone who was a problem drinker or alcoholic or who used street drugs? *

Yes (1)

No (0)

Was a household member depressed or mentally ill or did a household member attempt suicide? *

Yes (1)

No (0)

Did a household member go to prison? *

Yes (1)

No (0)

Now add up your “Yes” answers and enter the total below: *

Questionnaire

What brings you to counseling at this time? Is there something specific, such as a particular event? Be as detailed as you can

What are your goals for counseling?

Have you seen a mental health professional before?

Yes

Specify all medications and supplements you are presently taking and for what reason.

If taking prescription medication, who is your prescribing MD? Please include type of MD, name and phone number.

Who is your primary care physician? Please include type of MD, name and phone number.

Do you drink alcohol?

Yes

Do you use recreational drugs?

Yes

Do you have suicidal thoughts?

Yes

Have you ever attempted suicide?

Yes

Do you have thoughts or urges to harm others?

Yes

Have you ever been hospitalized for a psychiatric issue?

Yes

If you are in a relationship, please describe the nature of the relationship and months or years together.

Describe your current living situation. Do you live alone, with others. With family, etc...

What is your level of education? Highest grade/degree and type of degree.

What is your current occupation? What do you do? How long have you been doing it?

Enter any other experience

Other that applies

Nutrition Assessment

Family History

Digestive Function

Good

Fair

Poor

Signs and Symptoms

Rate your Typical energy level

Excellent

Good

Fair

Poor

Lab & Diagnostic Area

Medications/Supplements (vitamins, Minerals, herbs, Medical foods, etc)

Dosage & Frequency

Height

Current Weight

Weight, 1 yr ago

Lowest adult weight

Highest adult weight

Desired weight

Waist

Hip

W/H

BMI

BAI

Does your weight affect the way you feel about yourself?

Comments

Exercise/ Activity

Yes

DIET & FOOD HABITS

Comment

What are your personal challenges to eating well?

Are you aware of any adverse food reactions (allergies/intolerances)?

Yes

Do you grocery shop?

Yes

Do you cook?

Yes

What percentage of meals do you eat out?

90 - 100%

75%

50%

< 50%

FOOD LOG

Include 3 typical days including a weekend day – do not change how you usually eat and include all food and beverages

Breakfast Time:

Lunch Time:

Dinner Time:

Snacks

Used with permission from the Integrative and Functional Nutrition Academy

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