Blue Lotus Treatment Center

Instructions

Please fill out this questionnaire on line so I can learn a little about you before our first appointment. Thank you! (Please do not fill out this form until you call and make your first appointment. Thank you!)

Your Name

Address

Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

Email

Cell Phone

Home Phone

Work Phone

Your Age

Gender

MaleFemale

Date of Birth

Place of Birth

Education

Occupation:

Employment Status

Household Members

Please list each member of your household, their age, occupation, relationship

Marital Status

If married, date married

If dating, how long have you been dating?

If you have a mate, their name, age, occupation, education

Previous Marriages, Dates & Cause of Termination

Describe your current health

Very goodGoodAveragePoor

List present health problems including allergies

Medications you are currently using

Please list name of medication, dosage, physician, reason

Have you ever experienced any trauma/abuse?

PhysicalSexualVerbalEmotional

Have you ever considered or attempted suicide?

If yes, please explain:

Have you participated in therapy in the past?

If you have participated in therapy, please list the dates, duration, reason for therapy, and if you found it helpful.

Please describe the reason you are here

How long have you had this problem?

How does this problem affect you in your life and your relationships with others?

What are your expectations in therapy?

What are your hobbies?

What are your recreational activities and how often do you enjoy them?

Describe yourself as a person:

How do you feel about your home life?

Three wishes I have:

Three fears I have:

Emergency Contact Name

Emergency Contact Address

Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

Email

New Patient Questionnaire

Please fill out this questionnaire on line so I can learn a little about you before our first appointment. Thank you! (Please do not fill out this form until you call and make your first appointment. Thank you!)

Please answer all the questions below:

Personal Information Section

Verification

306 S Prospect Ave

Clearwater, FL 33756

Phone: (727) 210-3372

COPYRIGHT 2022