206-547-HELP (4357)

Dr. Patrick Hart
Phone Contact is Always Best. Give me a call!
Your responses to the below confidential profile-summary questionnaire will allow us to discuss your needs by reference to the relevant information that you have provided to me before our first scheduled appointment.

The below fields will allow you to summarize your concerns about mental health issues, relationship problems, struggles with addiction – or whatever is bothering you. Just begin typing and let the words, ideas, and emotions flow freely . . .  This way, we will have something meaningful to work with when we meet.

This will allow us both to save time by gaining clarity about the challenges that confront you. Fill in the blanks below so that I can begin to provide you with the strongest recommendations for the help that you desire. All fields are optional! Just provide as much information as you wish. You may leave any of the below fields blank.

Patrick J. Hart Psy.D.
Seattle Psychologist Referrals: Psychotherapy and psychotherapist matching to help you find the right counselor for mental health counseling. Assessment to determine the right therapist and to explore the type of therapy that will best suit your needs.

Helping You Find The Right Help!

Contact Information
Full Name:
Email Address:
Phone Number:
Profile of Subject & Relationship to You
Relationship:
Age:
Drugs of Choice:
Frequency of Use:
Personality Changes:
Behavioral Changes:
Effects of Addiction
Others Affected:
Effect on You:
Effect on Family:
Resulting Problems:
Work or Occupation	Social
Health	Legal
Suicidal Ideas	High Risk Behaviors
Driving While Intoxicated	Overdose Risks
The Future
What do you want to see happen?
What do you predict will happen if nothing changes?