GENERAL REGISTRATION FORM
STRICTLY CONFIDENTIAL

Chronic Pain • Weight Loss • Stop Smoking • Excessive Drinking • Drug Abuse • Break Ups
Phobias • Gambling • Depression • Stress • Memory Improvement
 
Please complete this registration form and choose one or more of the following:
     
Date:  
Name: Marital Status:
Address: City/State/Zip:
DOB: Age: Occupation:
Phones/Contact:
Home: Work: Cell: Email:
Have you ever seen a (check all that apply)        
If yes, please give their name(s):
Where did you hear about us? (check all that apply)               
           (specify)
How were you referred to Dr. Smith?
Who is your physician and what is their specialty?
Physician's office location (City/State/Zip/Phone):
Do you object to us contacting him or her about your success?
Do you have any of these issues for which office or phone counseling may be utilized?
(Check all that apply)
Smoking Weight Loss Pain Management
Depression/Anxiety Anger Excessive Drinking
Nail Biting Stress Poor Sleep
Phobias/Fears Substance Abuse Sexual Issues
Gambling Break Ups Memory
Describe the problem(s) you are presenting with:
How long have you experienced this problem?
What makes it worst ?
Have you ever gotten relief from this issue?
If yes, how did you accomplish it?
Circle the strongest desire to take care of this issue, with 10 equaling the strongest.
 
For Excessive Drinking Only
 
What type of alcohol do you consume?
How much alcohol do you consume each day?
List three places or situations in which you drink the most: 1.      2.      3.
List three reasons you want to stop drinking:

1.

2.

3.
What methods have you used to stop drinking before?
Circle your strongest desire to stop drinking, with 10 equaling the strongest.
 
Questions about total cost of programs are addressed at the consultation. See more details at our Fee For Services Page. To secure your appointment for an hour evaluation for $35 which may also be applied to a therapy session, please submit the registration form and pay your evaluation fee on the next page.
Review the online video testimonials before your consultation
Please submit and bring in this form to your evaluation.
 
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