Fill out the form below before your first therapy session. Your information remains confidential and is submitted directly to Peggy Olsen.
First Name
Last Name
Street Address
City
State
Zip
Home Phone
Work Phone
Cell Phone
E-Mail
Sex
Please Choose Male Female
Marital Status
Married Single Divorced Widowed/Widower Please Choose
Date of Birth
Place of Birth
Emergency Contact
Referred by
Number of Siblings
Please Choose 1 2 3 4 5 6 7 8 9 10
Sex and ages of Siblings
Spouse’s Place of Birth
Number of Spouse’s Siblings
Sex and Age of Spouse’s Siblings
Have you ever had Counseling
Please Choose Yes No
Are you on any medications?
List all medications
Are you currently under the care of any health care professional?
Explain
Do you frequently suffer from stress?
Do you experience frequent headaches?
Have you ever been in an accident? Please include DATE.
Briefly detail any trauma occurrence in your life; death, accidents, war, attack.
Any Fall? Include Date(s)
Any surgeries? Include Date(s)
Intention for coming?
Please tell me anything you know about your birth, were you born in a hospital or at home? Was it Vaginal? Was your mother under anesthesia? Did you spend time in an incubator? Were you breast fed?
Are there any conditions I should be aware of?
Please use this area to explain in detail anything you feel you need to:
