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Intake Questionnaire 

Please fill out the following form to help us understand your overall wellness condition.

How were you refered to Calm Mind Behaivioral Counseling
Your Insurance Carrier
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The subscriber is the person who pays for health insurance premiums or whose employment is the basis for membership in the insurance plan. If you are not the subscriber...


Rate quality of relationship
PoorFairGoodVery goodExcellent
Do you have children
Childrens develpmental level

Health Information

Rate your physical health.
PoorFairGoodVery goodExcellent
Please select any chronic heath condition
Do you have dificulty sleeping?
Please describe any sleep difficulties
Do you exercise routinely?
Please describe exercise
Do you have any problems or concerns about your appetite or food intake?
Please describe Appetite
Have you experianced significant weight change in the past 2 months?
Please describe Weight
Do you regularly drink alcohol?
Please describe Alcohol
Do you engage in recreational drug use?
Please describe Drugs

Psychiatric Information

What prompted you to seek counseling? Select all that apply.
Have you been in counseling before?
Have you ever been diagnosed with an mental illness.
Are you or have you ever been prescribed psychiatric medications?

Thanks for submitting!

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