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What is the reason for seeking care?

Anxiety Attentional difficulties Behavioral issues Depression Grief Relationship issues Trauma Other

What mental health concerns or treatment have occurred in the past?

In therapy now In therapy in the past Taking psychiatric medication now Taken psychiatric medication in the past Hospitalized for mental health reasons now or recently Hospitalized for mental health reasons in the past Known neurologic or genetic disorder Attempted suicide in the past None of these apply

Legal / Court Involvement

Are there any current or anticipated legal, court, custody, immigration, workplace, school, or other third-party proceedings related to the concerns you are seeking therapy for? If yes, please briefly describe in the “Is there anything you would like me to know?” section. Please note: Relationship Works provides psychotherapy services and does not provide forensic evaluations, custody evaluations, legal opinions, or therapy for the primary purpose of producing court documentation or testimony.

Yes No

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