Please print out this form, complete it and mail it to Dr. Kracke & Associates, P.A. 422 17th Street Lewiston, Id. 83501.  Or you can bring it with you at the time of your first appointment. NAME:____________________________                               AGE:___________ DATE:_____________ DATE OF FIRST APPOINTMENT:_______________ BRIEFLY DESCRIBE YOUR CONCERNS:________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ HOW LONG HAVE THESE CONCERNS BEEN PRESENT:__________________________________

ARE YOU FEELING DEPRESSED ?   YES    NO       HOW LONG:___________________________ ARE YOU FEELING ANXIOUS    ?    YES    NO       HOW LONG:___________________________ PLEASE CIRCLE ANY OF THE FOLLOWING PROBLEMS WHICH PERTAIN TO YOU: NERVOUS               PHOBIC               SHYNESS                SUICIDAL THOUGHTS FEARFUL                SEPARATION      DIVORCE                SEXUAL PROBLEMS FINANCES              DRUG USE          ALCOHOL USE        SELF-CONTROL FRIENDS                ANGER                UNHAPPINESS        RELAXATION HEADACHES          TIREDNESS          MEMORY                LEGAL MATTERS AMBITION             ENERGY               INSOMNIA              MAKING DECISIONS LONELINESS         EDUCATION         MARRIAGE             INFERIORITY FEELINGS TEMPER                NIGHTMARES       APPETITE               CONCENTRATION PARENTING          BOWEL TROUBLE  CHILDREN             CAREER CHIOCES COMPULSIONS     OBSESSIONS        MY THOUGHTS       STOMACH TROUBLE RELATIONSHIPS   SOCIAL-INTERACTIONS                      STRESS DISORDERS HOW WOULD YOU DESCRIBE YOUR HEALTH  (EXELLENT, GOOD,  FAIR,  POOR) ?                       PHYSICAL __________________         EMOTIONAL________________ LIST ANY MAJOR HEALTH PROBLEMS:________________________________________ ___________________________________________________________________________ LIST ANY EMOTIONAL DIFFICULTIES:________________________________________ ___________________________________________________________________________ HAVE YOU BEEN SEEN BY ANOTHER COUNSELOR ?  YES  NO .  IF YES, WHOM HAVE YOU SEEN _________________ AND WHEN WERE YOU SEEN _____________________ THANK YOU FOR COMPLETING THIS INFORMATION, IT WILL HELP YOU AND YOUR THERAPIST GET STARTED WORKING ON THE ISSUES YOU HAVE INDICATED.

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