Eagle Crest Wellness

Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Name of Parent/Legal Guardian

First Name

Last Name

Name of Parent/Legal Guardian

First Name

Last Name

Phone Number *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone Number of Emergency Contact

(###)

###

####

Please check any current or past experiences that impact you *

Anxiety/Stress

Addiction

Depression

Death of Someone Close

Cultural Concerns

Childhood Abuse

Extramarital Affair

Family Issues

Fertility Concerns

Food or Eating Issues

Friendships/Relationships

Gender Identity Concerns

Marital Issues

Pregnancy

Phobias

Racial Identity Concerns

Sexual Assault

Sexual Dysfunction

Sexual Preoccupation

Sexual Orientation Concerns

Sleep Issues

Spiritual Concerns

Substance Use (Including Alcohol & Marijuana)

Suicidal Thoughts

Trauma

Violence

Work/Academic Issues

Name Of Current Physician

First Name

Last Name

Have you seen a Counselor or Therapist before? *

Yes

No

Have you had any history of self-harm/suicide attempts? *

Yes

No