This is a strictly confidential patient medical record. It will be used to evaluate whether BeYOUtiful Minds & Fitness is appropriate for your health. None of the people you identify on this form will be contacted unless you provide express permission for BeYOUtiful Minds & Fitness to contact them.

Part One: Demographic Information
Name of Person Providing Information
Name of Person Providing Information
Date of Birth
Date of Birth
Home Phone
Home Phone
Cell Phone
Cell Phone
It is okay to leave a message at:
Person's Address
Person's Address
Please include name and age.
Partner/Spouse's Name
Partner/Spouse's Name
Partner/Spouse's Date of Birth
Partner/Spouse's Date of Birth
Person is looking for:
What is the main issue for which you are seeking help?
Medical Information
Have you ever been given a mental health diagnosis?
Have you, or a loved one, ever felt concerned about your eating habits?  
Have, or do you, over-exercise or experience symptoms of over-training? 
Have you ever been diagnosed with an eating disorder, an excessive exercise disorder, or body dysmorphic disorder?
Have you been to therapy before?
Do you have a current mental health therapist?
Do you have a current psychiatrist?
Did you list all of your current psychiatric medications above?
Have you ever attempted suicide?
In the last 12 months?
Do you currently feel suicidal?
Do you have a plan?
Do you have weapons in your home?
Can you contract to be safe until a therapist can contact you?
Has anyone in your family or anyone else close to you committed suicide?
Have you had thoughts of harming someone else?
Have you ever had trouble controlling your anger?
For example, arrested, throwing things, hit people/things.
Do you hear voices or see things that others don’t?
Do you feel safe in your home?
Is there any physical, emotional, or sexual abuse currently in your life or in your past?
Lifestyle Information
Are you currently working?
Have you experience any recent changes in your life?
One being the lowest you’ve ever experienced and 10 being the highest.
Do you have a desire to gain/lose weight?
How did you hear about us?

*Please understand that our agency may not be able to meet your individual needs.  For this reason, after the initial phone consultation or the in-home intake is complete we may refer you to an agency that is better able to suit your individual needs.