Intake Form

BACKGROUND INFORMATION

Name-Paddlemonster (the kayaking implement, or the rougher stuff, if you prefer)

Sex- Male, confused a little about what may be expected of me

Age- I'm in college, and not one of the creepy 40 year old freshmen

Ethnicity- White. I've got Cherokee heritage, but doesn't everyone?

Sexual Orientation- Heterosexual, but only making out, anything else would be too much at this point.

Preferred Method of Contact- Text message during my physiological psychology class

Academic Information- Currently a student, but that won't last much longer if this doesn't work.

Referred by- The people who said this was my only free option.

PRESENTING CONCERNS

Briefly describe what brought you in today- Dull and hollow affect, lack of sex and competitive drive, inability to concen....

LEVEL OF IMPACT

How much do these concerns interfere with your: (1-5)

Academic Performance-4

Emotional Well-Being-3

Social Activities-4

Daily Routine-2

MENTAL HEALTH HISTORY

Have you received mental health treatment in the past?- Nothing helpful, but definitely treatment of some kind.

Have you purposely injured yourself without suicidal intent?- Unless you count SG, no.

I just wanted to rid myself of my smart ass answers before I went to my appointment.  The therapist I am seeing is a woman, I am interested to see how that affects my perception. 

Either way, I am looking forward to it.