Name
*
First Name
Last Name
May we email you?
Yes
No
Home Phone
(###)
###
####
May we leave a message on your home phone?
*
Yes
No
Cell/Other Phone
(###)
###
####
May we leave you a message on your cell phone?
Yes
No
Gender
Male
Female
Transgender
Other
Birth Date
*
MM
DD
YYYY
Age:
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Emergency Contact
*
Relationship Status
Partnered
Married
Separated
Divorced
Widowed
Dating
Other
Number of Children
Number of Pregnancies
How did you hear of us?
Are you currently receiving psychiatric services, professional counseling or psychotherapy elsewhere?
If yes, please list providers names and contact information
List medications you are currently taking
Primary Care Doctor
Name, Practice, Address, Phone
1. How is your physical health at present?
Poor
Unsatisfactory
Satisfactory
Good
Very good
2. Please list any persistent physical symptoms or health concerns (e.g. chronic pain, headaches, hypertension, diabetes, etc.):
3. Are you having any problems with your sleep habits?
Yes
No
If yes, check where applicable:
4. How many times per week do you exercise? And for how long?
5. Do you require any accommodations as part of your participation in this retreat?
Yes
No
If yes, please describe:
6. Are you having any difficulty with appetite or eating habits?
Yes
No
If yes, check where applicable:
Have you experienced significant weight change in the last 2 months?
7. Do you regularly use alcohol?
Yes
No
Please describe your alcohol use.
In a typical month, how many drinks would you consume in a 24-hour period?
8. How often do you engage in recreational drug use? (This includes medications that are not prescribed to you as well and other drugs ex: cannabis, cocaine, psychedelics, etc.)
Daily
Weekly
Monthly
Rarely
Never
Please describe your current and past substance use:
9. Have you ever attempted suicide
Yes
No
If yes, when? And how many attempts have you made?
10. Have you had suicidal thoughts recently?
Yes
No
If yes, when?
Have you had them in the past?
11. Have you ever been hospitalized in the past for mental health reasons?
Yes
No
If yes, please describe:
12. Have you ever been in a situation where your safety or physical integrity was threatened. Examples may include: childhood abuse, intimate partner violence, unwanted sexual experiences, being the victim of a violent crime:
Yes
No
If comfortable please specify the type of experience that applies to you:
13. Have you ever experienced other kinds of potentially traumatic experiences? Examples: combat, assault, flood, fire, natural disaster, a bad accident?
Yes
No
If yes, and if comfortable, please provide a brief description:
14. Have you ever served in the military?
Yes
No
If yes, please describe (branch, length of service, type of discharge etc):
15. In the last year, have you experienced any significant life changes or stressors?
Yes
No
If yes, please describe:
Depressed Mood
Never
Current
Past
Mood Swings
Never
Current
Past
Rapid Speech
Never
Current
Past
Crying Spells
Never
Current
Past
Guilt
Never
Current
Past
Anxiety
Never
Current
Past
Risky Activity
Never
Current
Past
Irritability
Never
Current
Past
Panic Attacks
Never
Current
Past
Phobias
Never
Current
Past
Sleep Disturbances
Never
Current
Past
Hallucinations
Never
Current
Past
Unexplained losses of time
Never
Current
Past
Alcohol/Substance Abuse
Never
Current
Past
Frequent Body Complaints
Never
Current
Past
Disordered Eating (e.g., Binging, Purging, Restricting Diet, Diet Pills)
Never
Current
Past
Body Image Problems
Never
Current
Past
Repetitive Thoughts (e.g., Obsessions)
Never
Current
Past
Repetitive Behaviors (e.g., Frequent Checking, Hand-Washing, Counting)
Never
Current
Past
Thoughts of Harming Others
Never
Current
Past
Suicidal Ideation
Never
Current
Past
Suicide Attempt
Never
Current
Past
Self-Injury (e.g., cutting, burning)
Never
Current
Past
Please describe any past experiences (include month and year):
What do you consider to be your strengths?
What do you like most about yourself?
What are the effective coping strategies that you use?
What are your goals for this retreat?
Is there anything else about you we should know?
