Lyris Bacchus Steuber, MS, LMFT MT Harley Lester Lane Apopka, FL Ph: , Fax:

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Lyris Bacchus Steuber, MS, LMFT MT 2075 515 Harley Lester Lane Apopka, FL 32703 Ph: 407 417 7770, Fax: 407 862 4820 Please complete the following so I can have a better understanding of how I can help you. GENERAL INFORMATION Date: Full Name: Mr. Mrs. Ms. Miss Social Security: Age: Date of Birth: Race: White Black Hispanic Asian Other: Sex: Male Female Relationship Status: Single Married Divorced Separated Insurance Yes No Insurance Company: Insurance ID#: Authorization#: Insurance Address: Availability (Days,Times): CONTACT INFORMATION Address: City: State: Zip Code: May We Send Mail Here: Yes No Home Phone: ( ) Mobile Phone: ( ) Work Phone: ( ) May We Leave a Message Here: Email Address: May We Send Email Here: Yes No EMERGENCY CONTACT Name: Relationship: Home Phone: ( ) Mobile Phone: ( ) EMPLOYMENT INFORMATION Employer: Length of Employment: Occupation: Average Hours Worked Per Week: EDUCATION INFORMATION Last Year of School Completed: 9 10 11 12 GED College: 1 2 3 4 Other: Are You Currently in School: Yes No. If Yes, What Level: Degree Pursuing: RELATIONAL INFORMATION Current Relational Status: Single Dating Engaged Married Separated Divorced Widowed

Are You Content with Your Current Relational Status: Yes No. If No, Briefly Explain: If Married, How Long: Number of Previous Marriages for You: For Your Partner: If Separated or Divorced, How Long: If Widowed, How Long: Partner s Name: Mr. Mrs. Ms. Miss How Long Have You Known Your Partner: Age: Partner s Race: White Black Hispanic Asian Other: Partner s Sex: Male Female Partner s Occupation: Average Hours Worked Per Week: Last Year of School Partner Completed: 9 10 11 12 GED College: 1 2 3 4 Other: What Words Would You Use to Describe Your Partner: Is Your Partner Supportive of You Seeking Counseling: Yes No Unsure Partner Doesn t Know With Whom Do You Currently Live (Check All that Apply): Alone Spouse Children Parent(s) Sibling(s) Boyfriend Girlfriend Roommate Other: CHILDREN Name Sex Age Relationship to You (natural, adopted) Living with You? Describe Him/Her Have You Ever Placed a Child for Adoption: Yes No. If Yes, When: Have You Ever Had a Miscarriage or Medical Abortion: Yes No. If Yes, When: Are There Any Custody/Visitation Issues: Yes No. If Yes, Elaborate: FAMILY OF ORIGIN List Mother, Father, Brothers, Sisters, Step Family, and Any Other Family Members who Effected You Positively or Negatively: Name Sex Age Relationship to You (e.g. mother, sister) Occupation Feelings About Relationship

MEDICAL INFORMATION Primary Physician: Phone: ( ) Address: City: Zip: Specialty (e.g. Family Practice, OB/GYN, Internal Medicine): Are You Currently Receiving Medical Treatment: Yes No. If Yes, Please Specify: List Any Conditions, Illnesses, Surgeries, Hospitalizations, Traumas or Related Treatments You Have Had (Use Back if Necessary): MEDICATIONS List All Current Medications You Are Taking, Including those You Seldom Use or Take Only as Needed (Use Back if Necessary): Medication: Dosage: Improves Prevents Controls: Medication: Dosage: Improves Prevents Controls: Are You Taking these Medication(s) According to Your Doctor s Recommendations: Yes No If No, Briefly Explain: PHYSIOLOGICAL SYMPTOMS Please Check Any of the Following Physiological Symptoms/Sensations that Apply to You Presently, or in the Recent Past: Headaches.... Past Present Dizziness... Past Present Stomach Trouble.. Past Present Visual Trouble. Past Present Sleep Trouble.... Past Present Trouble Relaxing.. Past Present Weakness. Past Present Tension. Past Present Rapid Heart Rate.. Past Present Difficulty Breathing. Past Present Intestinal Trouble.. Past Present Hearing Noises. Past Present Change in Appetite.. Past Present Tiredness... Past Present Pain Past Present Hearing Voices Past Present Seeing Things.... Past Present Other. Past Present Your Height: Your Weight: How has Your Weight Change in the Last 2-3 Months: CURRENT STATUS Please Check Any of the Following Problems which Pertain to You and/or Your Family: Stress Past Present Nervousness. Past Present Anxiety.. Past Present Panic. Past Present Unhappiness. Past Present Depression... Past Present Guilt.. Past Present Apathy... Past Present Terminal Illness... Past Present Recent Death. Past Present Grief.. Past Present Hopelessness.. Past Present Inferiority Feelings Past Present Defective Feelings. Past Present Loneliness.. Past Present Shyness.. Past Present Fears.. Past Present Friends... Past Present Marriage Past Present Communication. Past Present Physical Abuse... Past Present Emotional Abuse... Past Present Verbal Abuse. Past Present Sexual Abuse... Past Present Temper.. Past Present Anger. Past Present Aggressiveness... Past Present Bad Dreams... Past Present Concentration... Past Present Racing Thoughts. Past Present Unwanted Thoughts... Past Present Memory. Past Present Loss of Control Past Present Impulsive Behavior Past Present Self-Control... Past Present Compulsivity... Past Present Sexual Problems. Past Present Pregnancy.. Past Present Abortion... Past Present Legal Matters... Past Present Trauma... Past Present Eating Problems... Past Present Drug Use. Past Present Alcohol Use.... Past Present Trouble with Job.. Past Present

Career Choices Past Present Ambition Past Present Making Decisions Past Present Children... Past Present Being a Parent.... Past Present Finances.... Past Present Recent Loss. Past Present Disaster.. Past Present Other. Past Present Please Elaborate on Any of the Following Above: LEVEL OF DISTRESS Indicate How Distressed You Are by Placing an X on the Scale Below (1 = Very Little Distress; 10 = Extreme Distress): 1 2 3 4 5 6 7 8 9 10 Are You Currently Experiencing Any Suicidal Thoughts: Yes No. Have You Experienced Them in the Past: Yes No Have You Ever Attempted Suicide: Yes No. If Yes, When and How: Have Any of Your Friends or Family Ever Committed or Attempted Suicide: Yes No If Yes, Who & When: CURRENT ISSUES AND GOALS Please Describe Why You Are Coming to Counseling (i.e. What Are Your Issues, Problems?): Why Have You Decided to Come for Counseling Now: What Do You Hope to Gain or Change by Coming for Counseling: How Long Do You Believe Counseling Should Last: PREVIOUS COUNSELING List Any Previous Counseling, Psychiatric Treatment, or Residential/In-Patient Care You Have Received (Use Back If Necessary): Therapist: Location: Dates: Reason: Therapist: Location: Dates: Reason: RELIGIOUS BACKGROUND What Words Would You Use to Describe Yourself: If God Were to Describe You, What Would He Say: Briefly Describe the Religious Environment of Your Home as You Were Growing Up: Complete the Following Thought: God Is Do You Regularly Attend a Place of Worship: Yes No. If Yes, Where: What Is the Name of Your Pastor, Priest, Rabbi, or Other Spiritual Leader: Do You Have a Personal Support System: Yes No. If Yes, Who: I have answered all questions to the best of my ability and attest the above information is true:

Signed: Date:

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