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Please call 845-956-0122  to book an appointment.              If this is your first time, please complete the form below.

Hey There

Allow us to grab some important information so we can get you started as soon as possible. 

Making an appointment made simple!


Divine Counseling and Wellness, INC

131 Wickham Ave, Middletown, NY, 10940 

Biographic information

Medical History

Are you allergic to any medications?
Are you allergic to any other substances?
Have you ever donated blood?
Have you had any medical illnesses in the past?
Do you authorize me to communicate with your physician?
Have you had any surgical operations or injuries?
Have you ever had a seizure?
Have you ever had a head injury?
Do you authorize me to communicate with him/her?
Do you use non-prescription medications? If yes, which ones?
Do you currently use or have you ever used recreational or illegal drugs? If yes, which drugs and how often?
Do you drink alcohol?
Have you ever tried to cut down on how much you drink?
Have you felt guilty about anything resulting from your drinking
Do you feel better if you have a drink early in the day?

Family Psychiatric History

Relationship History

Do you engage in safe sex?
Do you have any sexual concerns?

Family Medical History

  • Decreased vision/ eye path 

  • Dizziness/Vertigo 

  • Decrease in hearing 

  • Chest 

  • Decrease in energy 

  • Difficulties with organization 

  • Cough/ Asthma 

  • Menstrual/ reproductive problems/infection 

  • Decrease in appetite 

  • Nausea/ vomiting/ diarrhea 

  • Bloody or black stool 

  • Frequent or Severe headaches 

  • Self-induced vomiting with or without ipecac

  • Anxiety/panic attacks 

  • Sleep difficulty 

  • Racing Thoughts 

  • Wear eyeglasses/ contacts 

  • Earaches/ buzzing or other sounds 

  • Difficulty Swallowing 

  • Shortness of Breath 

  • Difficulty concentrating/distractibility

  • Impulsivity 

  • Abdominal pains

  • Eating problems 

  • Using laxatives/diuretics or diet pills for weight loss 

  • Weight Loss/Weight Gain 

  • Blood in Urine

  • Convulsions/ Seizures 

  • Depression

  • Avoidance of public places

  • Decrease in motivation 

  • Suicidal thoughts/ fears 

Does your primary care physician know about the symptoms you have listed
Have you ever been exposed to abuse?
Are you distressed about any part of your appearance?



Have you performed any military service?
Have you been released on honorable discharge?
Have you served during the war time?


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