JotForm

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
Full Name *

First Name Last Name
E-mail *
Is it ok to contact you at your email address?

Yes No

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Birth Date *

Month Day Year
Phone Number *

- Area Code Phone Number
Is it ok to leave a voicemail message?

Yes No
What kind of appointment reminder would you like?
Cell Phone Carrier
Insurance ID Number
Insurance company
Emergency contact: name/ number
Additional Demographics
Race/ Ethnicity (check all that apply) *

American Indian/Alaska Native Asian Indian Bangladeshi Black/ African/ African-American Cambodian Chinese/ Chinese-American Filipino/ Filipino-American Hawaiian/ Pacific-Islander Japanese/ Japanese-American Korean/ Korean-American Mexican/ Mexican-American/ Chicano Middle Eastern Other Spanish-American/ Latino (includes Cuban, Puerto Rican, Central American, South American) Vietnamese/Vietnamese American White/ Caucasian Other option
Gender *

Male Female Transgender Prefer not to answer
Sexual Orientation *

Heterosexual Bisexual Questioning Gay Lesbian Transsexual Prefer not to answer Other option
Current Occupation
Relationship status
Treatment History
Have you had counseling/ psychotherapy in the past

Yes No
Have you taken psychiatric medicine in the past?

Yes No
Have you ever been psychiatrically hospitalized?

Yes No
Presenting Concerns
In your own words, please briefly describe your primary concern
How long have your concerns been bothering you?

Please rate your current level of distress regarding this/ these concerns.

	1	2	3	4	5
Low						High

To what extent does your concern interfere with occupational or social functioning, or more generally, your daily routine?

	1	2	3	4	5
Low						High

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.

During the past TWO WEEKS, how much (or how often) have you been bothered by the following problems? *

	0 - None, Not at all	1 - Slight, Less than a day or two	2 - Mild, Several days	3 - Moderate, More than half the days	4 - Severe, Nearly every day
1. Little interest or pleasure in doing things?
2. Feeling down, depressed, or hopeless?
3. Feeling more irritated, grouchy, or angry than usual?
4. Sleeping less than usual, but still have a lot of energy?
5. Starting lots more projects than usual or doing more risky things than usual?
6. Feeling nervous, anxious, frightened, worried, or on edge?
7. Feeling panic or being frightened?
8. Avoiding situations that make you anxious?
9. Unexplained aches and pains (e.g., head, back, joints, abdomen, legs)?
10. Feeling that your illnesses are not being taken seriously enough?
11. Thoughts of actually hurting yourself?
12. Hearing things other people couldn’t hear, such as voices even when no one was around?
13. Feeling that someone could hear your thoughts, or that you could hear what another person was thinking?
14. Problems with sleep that affected your sleep quality over all?
15. Problems with memory (e.g., learning new information) or with location (e.g., finding your way home)?
16. Unpleasant thoughts, urges, or images that repeatedly enter your mind?
17. Feeling driven to perform certain behaviors or mental acts over and over again?
18. Feeling detached or distant from yourself, your body, your physical surroundings, or your memories?
19. Not knowing who you really are or what you want out of life?
20. Not feeling close to other people or enjoying your relationships with them?
21. Drinking at least 4 drinks of any kind of alcohol in a single day?
22. Smoking any cigarettes, a cigar, or pipe, or using snuff or chewing tobacco?
23. Using any medication without a doctor’s prescription or using illicit drugs (marijuana, cocaine, ecstasy, LSD, heroin, inhalants, methamphetamine etc.)?

Should be Empty:

Lee M. Stillerman, PhD - New Client Information Form

Contact Information

Additional Demographics

Treatment History

Presenting Concerns

Symptom Rating Scale