Personal Information

Medical History

Current medical conditions *

Past medical conditions and surgeries *

Family medical history, especially regarding mental health *

Current medications and supplements, including dosages *

Allergies to medications or other substances *

Mental Health History

Previous psychological diagnoses *

Prior and current treatments, including medications and therapies *

Mental health symptoms and their severity *

History of hospitalizations for mental health concerns *

Lifestyle Factors

Dietary habits *

Exercise and physical activity *

Substance use TobaccoAlcoholRecreational Drugs

Sleep patterns *

Emotional and Social Wellness

Relationships and social support network *

Work-life balance and occupational stressors *

Coping mechanisms and stress management techniques *

Complementary Therapies

Experience with or interest in complementary therapies (e.g., acupuncture, herbal supplements, mindfulness, etc.) *

Spiritual and Cultural Background

Religious beliefs or spiritual practices, if any *

Cultural background and any culturally-specific health beliefs or practices *

Other Specific Questions/Concerns

Main concerns or symptoms that led to seeking treatment *

Personal goals for therapy or treatment *

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