INFO 2 — Vanessa Levine-Smith

ID number received

Who, if anyone, do you currently live with? (Please list first names only)

How is your general health?

Which if any medications are you currently taking?

Are you presently being treated for any physical or psychiatric condition?

Please give ranges for your weekly substance use (include alcohol, CBD/marijuana, psychedelics, opioids, etc)

Please describe past psychiatric treatment, hospitalizations and diagnoses.

Please list psychiatric diagnoses in your family.

Please note your age for any experiences you would describe as traumas. (Trauma includes emergency situations that you experienced directly or witnessed. They also include chronic relational neglect and abuse).

Have you had any major losses in recent years?

Have you had any thoughts of hurting others, hurting yourself or ending your life?

How would you describe your religion/spirituality?

What makes you feel strong, peaceful, or most alive?

What is the change you would most like to see during your time in therapy?

What traits do you like or admire in your partner?

Please write anything else that may be important.

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