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number of your referring doctorWill your evaluation be requested by anyone besides your referring physician?YesNoWill your evaluation be requested by an attorney or used for legal purposes?YesNoIs there a history of this problem or a precipitating event?YesNoIf yes, what?Have you had a previous evaluation?YesNoIf yes, with who?List current or chronic medical problems.Have you had neuroimaging (MRI/CT/PET), EEG, or lab work done in the last year?YesNoIf yes, list results:Current Prescriptions, Dosages, Date Prescribed:Allergies:History of trauma or abuse (physical, sexual, or emotional)Educational Background (include highest level of education)Occupational Background (include jobs held for past 5 years/if retired then when retired and how long in that occupation)Have you served in the military?YesNo If yes, please list dates of service and discharge rankHistory of arrests, court proceedings or other legal issues which have you have been involved:Previous Counseling (including provider 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