Proactive Therapy

Proactive Therapy

verb: to take action for your own health.

Complete the form as much or as little as you choose. Proactive therapy is a theory that humans need to take responsibility for their health, and they should have the tools to prepare their support team before a consultation. Electronic versions of this form are recommended to be sent electronically or delivered to the treating health provider prior to a scheduled consultation appointment to increase the value of time for all stakeholders. Support your provider’s office by keeping answers honest, short, to the point, and on a single page. Don’t ruin a good thing.


If you are suicidal or having a medical emergency: dial 911

National Suicide Prevention Lifeline: dial 1-800-273-8255

This is a free tool to help communication between humans and not for any medical advice. Email to request the document be emailed.



Misty Jones, RN

Sharp Rees-Stealy

#proactivetherapy #therapy




Date of Birth:

Sexual Identification:


Physical activity:

Tobacco use:                           How much?

Marijuana use:                         How much?

Illicit drug use:                    How much?

Alcohol consumption:             how much?

Sexual activity:

Do you have children?

Do you have siblings?



Signification other:

Mother’s Name:          Age:    Education Level:          Ethnicity:

Father’s Name:            Age:    Education Level:          Ethnicity:

Marital Status of patient’s parents as a couple:

Are your basic needs met?

Sleep pattern/hours:

Are your emotional needs met?

Do you have physical pain?

Are you or have you ever had suicidal thoughts/plans?

Do you have emotional pain?

Have you personally been affected by a type of pain not listed?

Current prescribed medications:

Current non-prescribed medications:

Past Medical/Surgical History:

Past Emotional History:

Previous types of therapy:

How often do you exercise & what are your activities?

Where do you work and how often?

What are your major concerns?

Do you think you need a referral to a specialty department?

Do you think you need a new medicine?

Do you think you have an undiagnosed disease/disorder:

I am here to see you for:

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