Counseling Registration

Section Break

First Name

Last Name

Age

Date of Birth (DD/MM/YY)

Street Address Address Line 2 City State ZIP Code

Home Phone

Cell Phone

Email

How did you hear about us?

What type of insurance do you have?

Consent

As a client at PreventEd, you have certain rights to privacy, or confidentiality. Any information shared in your session withan PreventEd counselor will remain confidential, unless you give consent to disclose certain information. However, underspecific circumstances, it is required by law or professional guidelines that information discussed in therapy be disclosed. These circumstances include: 1) intent to harm oneself; 2) intent to harm someone else; 3) involvement in activities that could harm you or others; or 4) report of abuse (physical, emotional, or sexual).

Except for situations as described above, no one will be given specific information you disclose in the counseling
sessions at PreventEd.

I have read and understand the policies explained in the Informed Consent section of this form.

Adult Assessment Questionnaire

Over the past month, how often have you been bothered by any of the following problems?

Little interest of pleasure in doing things

Not at all
Several days
More than half the days
Nearly every day

Feeling down, depressed, or hopeless

Not at all
Several days
More than half the days
Nearly every day

Trouble falling or staying asleep

Not at all
Several days
More than half the days
Nearly every day

Sleeping too much

Not at all
Several days
More than half the days
Nearly every day

Question in questionnaire appears here

Not at all
Several days
More than half the days
Nearly every day