Eagle Crest Wellness

Name 1 *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Phone Number *

(###)

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Name 2 *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Phone Number

(###)

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Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Address 2 (If Applicable)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone Number of Emergency Contact

(###)

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Please check any current or past experiences that impact your relationship *

Anxiety/Stress

Addiction

Depression

Death of Someone Close

Cultural Concerns

Childhood Abuse

Extramarital Affair

Family Issues

Fertility Concerns

Food or Eating Issues

Gender Identity Concerns

Phobias

Pornography

Pregnancy

Racial Identity Concerns

Sexual Assault

Sexual Dysfunction

Sexual Preoccupation

Sexual Orientation Concerns

Sleep Issues

Spiritual Concerns

Substance Use (Including Alcohol & Marijuana)

Suicidal Thoughts

Trauma

Value Differences

Violence

Work/Academic Issues

Name Of Current Physician 1

First Name

Last Name

Name of Current Physician 2

First Name

Last Name

Have either of you had any previous suicide attempts? *

Yes

No