Individual Info–Mental Health Please enable JavaScript in your browser to complete this form.Client Name *FirstLastMajor reason for seeking help at this time? *How long has this been a problem or concern? *Have you previously sought help for this? *Have you been treated previously by a psychiatrist, psychologist, therapist or counselor for other problems or concerns? If so, when and with whom? *Do you have recurring nightmares? If yes, please describe.Who loved you unconditionally from 0 to 18 years of age? Who gave you positive reinforcement?Who loves you and supports you in your life now?What characteristics do you like most about yourself?Do you have performance goals you would like to meet?How did you choose Pitts Davis Counseling for help? *Did someone refer you, and if so, who? *Client Signature *Clear SignatureToday's Date *Submit