General Information

Today's Date * +

First Name *

Last Name *

Preferred Name

Date of Birth * +

Primary Language *

English

Spanish

Other: Other:

Gender Identity *

Sexual Orientation? *

Gender Pronoun *

Contact Information

Current Address (If no address put "N/A" )

City

State

Zip Code

Email Address (If no email type "N/A")

Best Number To Reach You

Can Voicemail Messages Be Left For You To Receive? *

No

Yes

N/A

Aside Fom Telephone Calls, Please Let Us Know How You Would Like To Receive Information and Notifications From Our Team. *

Email

Text Message

Voicemail

Personal Information

What Is Your Current Living Situation? *

Current Relationship Status? *

Do You Have Children? *

No

Yes

Unsure

Ethnicity *

Hispanic

Not Hispanic

Race *

Grade of Education Last Completed *

Are You A Current Student? *

No

Yes

Do You Have Current or Prior Military Service? *

No

Yes

Who Did You Grow Up With? *

What Is Your Income Source(s)? *

Health Questionaire

What Is Your Overall Health? *

Excellent

Good

Fair

Poor

Have You Ever Been In Counseling/Therapy Services? *

No

Prefer Not To Disclose

Yes

If Yes, When? Also, What Were The Most Helpful and Least Helpful Parts Of Your Prior Therapeutic Experience(s)?

In The Last 2 Weeks Have You Used Any Substances? *

No

Prefer Not To Disclose

Yes

If Yes, What Substances Have You Used (If No, Type "N/A")?

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Are You Currently Taking Any Medications? *

No

Prefer Not To Disclose

Yes

If Yes, What Medications Are You Taking?

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Do You Have Any Preferences For A Counselor? *

No

Yes

If Yes, What Is Your Preference(s)?

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What Is Your Availability?

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Level Of Care Services? *

Outpatient (OP) Behavioral Health Services (Office Visit)

Online Counseling Services (Video or Audio)

Reason For Referral To Mental Health Services/Therapy.

Please Check All That Apply. *

Over The Past 2 Weeks, How Often Have You Been Bothered By Any Following Problems?

1. Little Interest Or Pleasure In Doing Things. *

2. Feeling Down, Depressed, or Hopeless. *

3. Trouble Falling Asleep or Staying Asleep, or Sleeping Too Much. *

4. Feeling Tired or Having Little Energy. *

5. Poor Appetite or Overeating. *

6. Feeling Bad About Yourself -- or That You Are A Failure or Have Let Yourself or Your Family Down. *

7. Trouble Concentrating On Things, Such As Reading The Newspaper or Watching Television. *

8. Moving or Speaking So Slowly That Other People Could Have Noticed Or The Opposite -- Being So Fidgety or Restless That You Been Moving Around A Lot More Than Usual. *

9. Thoughts That You Would Be Better Off Dead, or Of Hurting Yourself In Some Way. *

10. If You Are Experiencing Any Of The Above Problems, How Difficult Have These Problems Made It For You To Do Your Work, Take Care Of Things At Home, Or Get Along With Other People? *

The undersigned client* or responsible adult** consents to and authorizes mental health services by: The AMAAD Institute These services may include psychological testing, psychotherapy/counseling, rehabilitation services, medication, case management, laboratory tests, diagnostic procedures, and other appropriate services. While these services may be delivered at a different location, services provide within the Los Angeles County mental health system will be coordinated by the staff of a single agency. *

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