New client Questionnaire | Virginia Therapy S

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First name*

Birthday*

Month

Day

Year

Last name*

Email*

Phone*

Address

Feeling down or Hopeless *

Not at All

Sometimes

Often

Daily

Trouble sleeping or sleeping too much*

Not At all

Sometimes

Often

Daily

Difficulty concentrating*

Not at all

sometimes

Often

Daily

Feeling anxious and on edge*

Not at All

Sometimes

Often

Daily

Do you currently use or have a history with any of the following?

Have you experienced any of the following?*

How would you describe your current support system?

Are there current relationship challenges you’d like to address in therapy?

Is there anything else you’d like us to know before we get started?

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