Kathy Radina, M. Ed.
Licensed Professional Counselor
PO Box 4410 Cave Creek, AZ 85327
480-488-6096

Name _____________________________________________________________ Age _________Date of Birth ________________
Address ____________________________________________________________ City ________________Zip ________________ Occupation _________________________________________________________Employer ________________________________ Best numbers where you can be reached? Please indicate cell, work or home and at which numbers I may leave a message. __________________________________________________________________________________________________________ Partner Name ______________________________________________________ Age _________ Date of Birth ________________ Occupation _______________________________Employer ________________________Phone ____________________________ Children Names and Ages ______________________________________________________________________________________
Current Living Situation: Alone, With Partner, With Parents, Roommate, Other ________ Relationship Status (M, W, D) __________ Referred by __________________________________________Person to call in case of emergency ___________________________ Relationship _____________________________Phone ______________________________________________________________

Are you currently under the care of a Physician, Psychologist or Psychiatrist? ________ Name ______________________________ Address ________________________________________________________________Phone ______________________________ Reason for care? ____________________________________________________________________________________________ Have you been hospitalized for any reason over the past five years? _________Reason?____________________________________ Please list any medications, drugs, or over the counter remedies you take, and for what. ____________________________________ ___________________________________________________________________________________________________________

Have you had counseling in the past? ________ With whom? _________________________________________________________ Diagnosis or reason for therapy? _______________________________________________________________________________ What did you like most about it? ________________________________________________________________________________ Least? ____________________________________________________________________________________________________

Are you currently in an emotional crisis? ______ If yes, please explain __________________________________________________
Please list any history of drug or alcohol abuse. ____________________________________________________________________
Please indicate any relevant history of loss i.e.; death, divorce, disability, other ___________________________________________ Please indicate any history of trauma or abuse. ____________________________________________________________________

If you are experiencing the following symptoms, please indicate if they are MILD, MODERATE or SEVERE;
Depression _________ Anxiety __________Panic __________ Anger __________ Sleep Dysfunction ________
Eating Dysfunction ________ Relationship problems ________ Work problems ________ Other _____________