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 Therapy Office of Maryasha Katz, LCSW

(831) 234-5813


To save time, you may print this, fill it out and bring to your first appointment.  Otherwise, I will invite you to fill it out at your first appointment.  If you have difficulty with reading/writing, or for any other reason,  we can fill this out together if you prefer.

Name______________________________  Date_________________________

Date of Birth______________________                        Age_________



Telephone Numbers________________________________________________

OK to leave a message?  Yes     No


How did you hear about my services?__________________________________

With whom are you now living?  (list people)_____________________________

Where do you reside?  __house  __hotel  __room  __apartment  __other

Significant relationship status:

__single  __engaged  __married  __domestic partners  __separated  __divorced

__remarried  __committed relationship  __widowed  __other

If intimately involved with another person(s), what is that person’s name, age, occupation?

Satisfaction with relationship?

What is happening in your life that has resulted in this appointment?

What would you like to see accomplished in therapy?


Chief Complaint (Check all that apply to you):


__Low energy                        

__Low self-esteem

__Poor concentration            




__Sleep Disturbance (more/less)

__Appetite disturbance  (more/less)

__Thoughts of hurting yourself                       

__Thoughts of hurting someone

__Isolation/social withdrawal




__Heart pounding/racing                                                       

__Chest pain



__Chills/hot flashes


__Fear of dying                        

__Fear of going crazy



__Obsessive/compulsive behaviors                                    

`__Thoughts racing

__Can’t hold onto an idea

__Excessive behaviors (spending, gambling)


__Not thinking clearly/confusion

__Feeling that you are not real

__Feeling that things around you are not real

__Lose track of time

__Unpleasant thoughts that won’t go away


__Easily agitated/annoyed

__Defies rules

__Blames others


__Use of drugs and/or alcohol  (If yes, how much are you using?)

__Use of prescription medications (If yes, which ones and how much are you using?)


__Physical abuse issues

__Sexual abuse issues

__Child sexual abuse issues

__Emotional abuse issues

__Domestic/partner violence

__Other problems/symptoms:

Previous outpatient therapy?              Yes             No

If yes, with whom?_________________________________________________

How did you feel about your experience and what was accomplished?

Previous hospitalizations?              Yes            No            Number of hospitalizations_____

If yes, when_______________________________________________________

What are some things that you feel like you are good at or are your strengths?

Please indicate if there is anything else you would like me to know:


Thank you for taking the time to fill this out.


Last revised 9/12

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