Carol Dallinga, LCSW, CGP, EMDR, New York State Licensed Clinical Social Worker.

Westchester County, New York. 914-447-9196. License #R027862-1


Name: __________________________________________ Date: _________________ 

Age: _____________ Date of Birth: __________________________________________ 

Marital Status: ____________________ (single, partnered, married, separated, divorced, widowed) 

Names & Ages of Children (if applicable): _____________________________________ 


Home Address: ___________________________________________________________ 


Email Address (optional): __________________________________________________ 

Phone Number(s): ________________________________May we leave a message Yes___________No_____________

Occupation: _____________________________________________________________ 

Emergency Contact Person’s Name and Phone Number: __________________________ 


Referred by: (name & phone number): ________________________________________ 

Reason for seeking therapy at this time: _______________________________________ 

Have you previous received any type of mental health services?  No Yes Previous Practitioner_________

Please list current prescription medication___________________________________________________


General and Mental Health Information

  1. How would you rate your current physical healthy?

Poor   Unsatisfactory   Satisfactory   Good   Very Good

  1. How would you rate your current sleeping habits?

Poor   Unsatisfactory   Satisfactory   Good   Very Good



  1. How many times per week do you generally exercise? __________________________
  2. Please list any difficulties you experience with your appetite or eating issues________


  1. Are you currently experiencing overwhelming sadness, grief or depression? No Yes

Length of time_______________________________________________________ 

  1. Are you currently experiencing anxiety, panic attacks or have any phobias? No  Yes 

Approximately when did you begin experiencing this? __________________________ 

  1. Are you currently experiencing any acute or chronic pain? No  Yes _______________ 

If yes, please describe____________________________________________________ 

  1. Do you drink alcohol daily? Weekly? Monthly? Infrequently? Never?
  2. How often do you engage in recreational drug use?

Daily?   Weekly?   Monthly?   Infrequently?   Never?

  1. Are you currently in a romantic relationship? No  Yes   How long?_______________ 
  2. What significant life changes or stressful events have you experienced recently? 


Additional Information

  1. Are you currently employed?  No   Yes

Current employment_______________________________________________ 

Do you enjoy your work?

  1. Do you consider yourself to be spiritual or religious   No   Yes


  1. What do you consider to be some of your strengths?


  1. What do you consider to be some of your weaknesses?


  1. What would you like to accomplish out of your time in therapy?





I understand that all fees are due at the time of service, and that at least 24 hours’ notice is required for cancellation of appointmentsShould I cancel my appointment less than 24 hours in advance, I understand that I will be responsible for paying the full fee charged for my session. By signing below I agree to all of the above. 

Signature of client: _________________________________ Date: _________________ 

Results Is the Name of the Game