HEIKE ZELNHEFER, LCSW
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As a new client, please complete the information below to the best of your ability.
The information you supply will enable me to provide a more effective service.
Basic Information About You
*
Indicates required field
Name
*
First
Last
Date of Birth
*
Age
*
For Transgender or Gender Fluid Individuals ONLY How would you like to be called?
*
What Pronouns do you use?
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Address: Street
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Email
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Phone Number
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City, State, Zip Code
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May I send an email?
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Yes
No
Option 3
May I leave a voice mail message?
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Yes
No
Option 3
Who were you referred by?
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Emergency Contact: Name
*
Emergency Contact: Relationship
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Emergency Contact: Phone Number
*
Do you have any Legal History?
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No
Yes
Legal History explained
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Please list any past charges (alcohol / drug related - DUIs / DWIs, domestic violence, assaults, arrests, incarcerations etc) and list times...
Family Information
What is your Native Language?
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Relationship Status
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Single
In a Relationship
Married
Widowed
Divorced
Separated
Do you have Children?
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Yes
No
Name and Gender of your Children
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Are your Parents alive / deceased?
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Both parents are living
Both parents are deceased
My mother is living
My father is living
Do you have Siblings?
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Yes
No
How many siblings do you have?
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Education / Employment
Educational Level completed?
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High School / GED
Some College
Associate Degree
Bachelor Degree
Master's Degree
Ph.D. / Doctorate
Neither
Employment: Are you currently ...
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Employed
Unemployed
Disabled
Have you served in the Military?
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Yes
No
Name of Employer / Length of Employment / Occupation
*
Military Branch
*
Army
Navy
Marines
Air Force
Do you have Combat Experience?
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Yes
No
How many times have you been deployed? If yes, how many Tours?
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Please fill this out if you have been deployed?
Discharge from the Military
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Honorable
Dishonorable
Medical History
Do you have any Medical Conditions?
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Heart Disease / High Blood Pressure
Migraines
Asthma
Epilepsy / Seizure Disorder
Allergies
Other
Medical Condition explained...
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Did you experience any trauma, accident, surgery etc...
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No
Yes
Trauma, Accident, Surgery explained
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Mental Health History
Family History of Mental Illness
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No
Yes
Family Mental Illness explained
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Family History of Suicide
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No
Yes
Family History of Suicide explained
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Have you ever been diagnosed with a Mental Illness
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No
Yes
Mental Illness Diagnosis explained
*
If you ever have been diagnosed with any Mental Illness, please explain what your diagnosis was, who you were diagnosed by, and when you were diagnosed.
Have you ever received Mental Health Services
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Yes
No
Mental Health Services explained
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If you ever have received any Mental Health Services, please list the practitioners, year, and length of service.
Have you ever been a patient in a Psychiatric Hospital
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Yes
No
Psychiatric Hospital explained
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Please list the number of inpatient psychiatric hospitalizations you had in your life, when you were hospitalized and where.
Are you currently taking any Psychotropic Medication
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Yes
No
Psychotropic Medication explained
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If you are currently on or if you ever have taken any psychotropic medication, please list here.
Did you ever suffer any type of abuse
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No
Yes
Abuse explained
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Please explain what form of abuse you suffered (molestation, sexual abuse, emotional abuse, physical abuse etc) and how old you were
Within the past 3 months, did you have any suicidal thoughts
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No
Yes: thoughts - no plan, no intent
Yes: thoughts and plan, no intent
Yes, thoughts, plan, and intent
Did you ever attempt suicide
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No
Yes, over 3 months ago
Yes, within the last 3 months
Do you have any thoughts of Self-Harm
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No
Yes
Suicidal ideation / Self Harm explained
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General Health Information
Do you exercise regularly
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No
Daily
1-3 times per week
4-5 times per week
Exercise explained
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Please list type and frequency (how often per day / week / month)
How many 8 oz glasses of water do you drink daily
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Not enough
1-3
4-8
How many meals per day do you eat
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1
2
3
4+
I eat smaller portions throughout the day
I mainly snack
Meals explained
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Within the last 3 months, your appetite ...
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My appetite has been the same
My appetite increased
My appetite decreased
I did not notice any change in appetite but I lost weight
Within the last 3 months, your sleep ...
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My sleep has been the same
I wake up once per night
I wake up every hour / every other hour
I have trouble falling asleep
I have trouble staying asleep
Social Information
Alcohol Use
*
Never
Socially / Occasionally
Once per month
Once per week / Weekends
Twice per week
3-5 times per week
Daily
Binge Drinking
Choose all that apply
Drug Use
*
Never
In the past / Not current
Pain Medication / Opioids / Heroin
Methadone
Crack / Cocaine
Marijuana
Amphetamines / Ecstacy/ Molly
Ayahuasca / Mescaline
Tobacco Use
*
Never
Cigarettes: less than a pack per day
Cigarettes: 1 pack per day
Cigarettes: more than a pack per day
Cigars
Vape
Alcohol / Drug / Tobacco Use explained
*
Please list any past experiences, sobriety times, detox / rehab visits ...
Self Development
Do you meditate
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No
I've tried it and did not like it / did not work
Daily
Sometimes
When I have time
Meditation explained
*
Please explain what form form of meditation you are practicing (guided v non-guided, silent, calming v insight oriented, focused, noting, body scan, visualization, loving kindness, awareness, skilled compassion, reflecting...)
Do you practice any religion / spiritual practice
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Yes
No
Sometimes
Religion / Spirituality explained
*
If you practice any religion, please explain what faith you practice. If you are spiritual / believe in a higher power please explain
Please explain the reason you are seeking counseling at this time
*
Thoughts & Feelings
Below is a list of different feelings and thoughts that affect Mind & Body. Please take a moment and
check all that apply
either currently or within the past 90 days (3 month)
.
Choose Any
*
Afraid
Angry
Anxious
Bullied
Burdened
Confused
Defensive
Depressed
Desperate
Disconnected
Embarrassed
Empty
Frustrated
Guilty
Helpless
Hopeless
Choose Any
*
Homicidal
Hurt
Insecure
Indifferent
Impatient
Irritated
Lonely
Lost
Misunderstood
Moody
Numb
Obsessive
Paranoid
Pessimistic
Racing Thoughts
Shameful
Choose Any
*
Stressed
Stuck
Suicidal
Tearful
Unappreciated
Unattractive
Unfulfilled
Unhappy
Unlovable
Unworthy
Weary
Worthless
Submit
home
Philosophy
Language Intention
Perception
Self-Responsibility
Services
Aromatherapy
Emotional Freedom Technique
Hypnotherapy
>
What to expect in a hypnosis session
Psychokinesiology
Psychotherapy
Reiki
Specialized Energy Kinesiology
Rates
Contact Me
About Me
Resources
Hotlines
Transgender Resources
Book Recommendations
Service Animal
Success Stories
Network
Blog