About MTG
Services
MTG Takeover
Events
MH&P Virtual Summit
MTG Combine
Training
Coaches
Contact MTG
Contact MTG
Referral Form
FAQ
About MTG
Services
MTG Takeover
Events
MH&P Virtual Summit
MTG Combine
Training
Coaches
Contact MTG
Contact MTG
Referral Form
FAQ
Client Information
Please fill out the information below.
Athlete First & Last Name
*
First Name
Last Name
Birth Date
(MM/DD/YYYY)
MM
DD
YYYY
Gender
School Attending / Grade
Sport(s) or training interest?
Parent or Guardian First & Last Name
First Name
Last Name
Email
*
Phone
(###)
###
####
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Client is a minor
Yes
No
Emergency Contact First & Last Name
First Name
Last Name
Relationship
Phone
(###)
###
####
Referral Source First & Last Name
First Name
Last Name
Agency
Email
Phone
(###)
###
####
Est. Start Date for Services
PO End Date
Presenting Problem? Be as detailed as you can.
What are your goals for the services?
Have you seen a mental health professional before?
Yes
No
If yes, please list current or previous services.
Please specify all medications and supplements you are presently taking and for what reason.
If taking prescription medication, who is your prescribing MD? Please include type of MD, name and phone number.
Who is your primary care physician? Please include type of MD, name and phone number.
Do you / athlete drink alcohol?
Yes
No
Do you/athlete use recreational drugs? (specify below if yes)
Yes
No
Have you/athlete had suicidal thoughts within the past 30 days?
Yes
No
Have you/athlete ever attempted suicide?
Yes
No
Do you/athlete have thoughts or urges to harm others?
Yes
No
Have you/athlete ever been hospitalized for a psychiatric issue?
Yes
No
Is there a history of mental illness in your family?
Yes
No
Describe your current living situation. Who lives in the home? (ex. mother, father, aunt 2 sibling ages 8 and 9)
What is your level of education? Highest grade/degree and type of degree.
What is your current occupation? What do you do? How long have you been doing it?
Please check any of the following you have experienced in the past six months
Depressed mood
Tearful or crying spells
Anxiety
Fear
Hopelessness
Panic
Increased appetite (due to Depression)
Decreased appetite (due to Depression)
Trouble concentrating
Difficulty sleeping
Excessive sleep
Low motivation
Isolation from others
Fatigue/low energy
Low self-esteem
Please check any of the following that apply
Headache
High blood pressure
Gastritis or esophagitis
Hormone-related problems
Head injury
Angina or chest pain
Irritable bowel
Chronic pain
Loss of consciousness
Heart attack
Bone or joint problems
Seizures
Kidney-related issues
Chronic fatigue
Dizziness
Faintness
Heart valve problems
Urinary tract problems
Fibromyalgia
Numbness & tingling
Shortness of breath
Diabetes
Hepatitis
Asthma
Arthritis
Thyroid issues
HIV/AIDS
Cancer
Other
What else would you like us to know?
Thank you!
