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Ann P. Smollon, LCSW-R
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New Patient Information
Please complete the form below
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Name
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Relationship Status
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Children
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What is your primary reason for attending sessions?
What is your secondary reason for attending sessions?
What would you like to accomplish?
How many sessions do you think you will need? (If unknown, write unknown)
Areas of Concern
Please rate the relevancy of the concerns listed below. Strongly Disagree being completely irrelevant and Strongly Agree being a primary concern.
Marriage
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Children
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Smoking
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Relationships
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Eating Disorders
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Alcohol
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Mood Swings
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Shyness
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
In-Laws
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Aging
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Divorce
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Addictions
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Sexual Issues
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Stress
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Past Hurts
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Drugs
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Loneliness
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Work
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Self-Esteem
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Co-Dependency
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Dating
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Weight
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Fear
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Phobias
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Parents
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Money
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Sleeping
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Communication
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Intimacy
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Referral source?
How were you referred to Ann?
Thank you!