Nancy Nguyen, LCSW

Expanding Pathways · San Jose, California

This helps me understand your background and current concerns before your first session. There are no right or wrong answers — please answer as honestly as you can. Everything here is protected under the same confidentiality policies described in your Notice of Privacy Practices.

Identifying information

Presenting concerns

Mental health history

Have you been in therapy before?

Yes No

Have you ever been psychiatrically hospitalized?

Yes No

Medical history

Your care team

Listing someone here does not give me permission to contact them. It only helps me understand who else is involved in your care. If we later decide it would be useful for me to speak with one of these people, you would sign a separate Release of Information first, and you would choose exactly what may be shared.

Psychiatrist or prescriber

Name

Practice or clinic

Phone

City

Medications they prescribe or manage

Previous or current therapist

Name

Practice or clinic

Phone

City

Would you like me to coordinate with any of the people above?

Yes No Not sure yet I'd rather discuss it

Either answer is fine, and you can change your mind at any time.

Substance use

Tobacco / nicotine (cigarettes, vape, etc.)

Never Former use Occasional Daily

Alcohol

Cannabis

Never Rarely Weekly Daily

Other recreational drug use, or non-prescribed use of prescription medication (please specify substance and frequency, or write "none")

Have you ever felt you should cut down on your drinking or drug use?

Yes No

Have you ever felt annoyed by others criticizing your use?

Yes No

Have you ever felt guilty about your drinking or drug use?

Yes No

Have you ever used first thing in the morning to steady your nerves?

Yes No

Have you received treatment for substance use in the past (rehab, detox, AA/NA, etc.)?

Yes No

Background

Have you experienced a significant trauma (abuse, violence, accident, loss)?

Yes No Prefer to discuss in person

Current safety

Are you currently having thoughts of suicide or self-harm?

Yes No

Have you attempted suicide or engaged in self-harm in the past?

Yes No

Are you currently having thoughts of harming someone else?

Yes No

If you answered yes to any question in this section and are in immediate danger, please call 911, go to your nearest emergency room, or call/text 988 (Suicide and Crisis Lifeline) right now.

Strengths and coping

I confirm that the information provided above is accurate and complete to the best of my knowledge.

Signature

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Your completed form has downloaded. Please email the downloaded PDF back to Nancy Nguyen, LCSW, or bring it to your first appointment.

Nancy Nguyen, LCSW

Identifying information

Presenting concerns

Mental health history

Medical history

Your care team

Primary care doctor

Psychiatrist or prescriber

Previous or current therapist

Substance use

Background

Current safety

Strengths and coping