• Lee M. Stillerman, PhD - New Client Information Form

    Welcome to my practice. I want to make the most of each appointment we have together. One way of doing this is for you to provide some basic information in advance of your first appointment. Please fill out the following as completely as possible. This information is confidential.
  • Contact Information

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  • Additional Demographics



  • Treatment History

  • Presenting Concerns

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  • Symptom Rating Scale

    DSM - 5 Self-rated Level 1 Cross-Cutting Symptom Measure - Adult
  • Instructions: The questions below ask about things that might have bothered you. For each question, check the number that best describes how much (or how often) you have been bothered by each problem during the past TWO (2) WEEKS. 

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  • Should be Empty: