Amy Lewis Bear, LPC, NCC
1788-B Century Blvd, Atlanta, GA 30345, 404-592-1256
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CLIENT INFORMATION FORM
*This Form is Confidential*
Today's date: ______
Your name: ______
Last First Middle Initial
Date of birth: ______Social Security #: ______Male___Female___
Home street address: ______
City: ______State: ______Zip:______
Name & address of employer:______
Home phone: ______Work phone: ______
Cell phone: ______Email: ______
Calls will be discreet, but please indicate any restrictions:______
Highest level of education completed: ______
Referred by: ______
- May I have your permission to thank this person for the referral?
Yes No
-If referred by another clinician, would you like for us to communicate with one another?
Yes No
Person(s) to notify in case of any emergency:______
Name Phone
I will only contact this person if I believe it is a life or death emergency. Please provide your signature
to indicate that I may do so: (Your signature): ______
Please briefly describe your presenting concern(s): ______
______
What are your goals for therapy?______
______
MEDICAL HISTORY:
Please explain any significant medical problems, symptoms, or illnesses: ______
______
Current medications:
Name of medicationDosage Purpose Name of prescribing physician
Page 2
Do you smoke or use tobacco?YESNOIf YES, how much per day?______
Do you consume caffeine?YESNOIf YES, how much per day? ______
Do you drink alcohol? YES NO If YES, how much per day/week/month? ______
______
Do you use any non-prescription drugs? YES NO
If YES, what kinds and how often? ______
Have any of your friends or family members voiced concern about your substance use? YES NO
Have you ever been in trouble or in risky situations because of your substance use? YES NO
Previous medical hospitalizations (approximate dates and reasons):______
______
Previous psychiatric hospitalizations (approximate dates and reasons):______
______
Have you ever talked with a psychiatrist, psychologist, or other mental health professional? YES NO
(approximate dates and reasons): ______
______
FAMILY, SOCIAL SUPPORTPERSONAL HEALTH:
POOR EXCELLENT
Currently in relationship? ____ How long? ____ Relationship satisfaction: 1 2 3 4 5 6 7
Married/life partnered? _____ How long? ____ Previously married/life partnered? YES NO
If so, length of previous marriages/committed partnerships______
Do you have children?____ If YES, how many and their ages:______
POOR EXCELLENT
Current level of satisfaction with your friends and social support: 1 2 3 4 5 6 7
FAMILY HISTORY OF (Please check all that apply):
Drug/alcohol problemsPhysical abuse Depression
Legal troubleEmotional abuse Anxiety
Mental illnessSexual abuse Hyperactivity
SuicideLearning disabilities “Nervous breakdown”
PLEASE CIRCLE ALL THAT APPLY:
Difficulty with:Difficulty with:Difficulty with:
AnxietyPeople in general Nausea
DepressionParents Abdominal distress
Mood changesChildren Fainting
Anger or temperMarriage/partnership Dizziness
PanicFriend(s) Diarrhea
FearsCo-worker(s) Shortness of breath
IrritabilityEmployer Chest pain
ConcentrationFinances Lump in the throat
Page 3
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HeadachesLegal problems Sweating
Loss of memorySexual concerns Heart palpitations
Excessive worryHistory of child abuse Muscle tension
Feeling manicHistory of emotional abusePain in joints
Trusting othersDomestic violence Allergies
Communicating Thoughts of hurting Often make careless
with otherssomeone else mistakes
DrugsHurting self Fidget frequently
AlcoholThoughts of suicide Speak without thinking
CaffeineSleeping too much Waiting your turn
Frequent vomitingSleeping too little Completing tasks
Eating problemsGetting to sleep Paying attention
Severe weight gain Waking too early Easily distracted by noises
Severe weight lossNightmares Hyperactivity
BlackoutsHead injury Chills or hot flashes
Any additional information you would like to include:______
______
______
CLIENT AGREEMENT:
I understand and agree that:
1. Payment is required prior to or at the beginning of the therapy session.
2. I am responsible for any and all fees.
3. I am required to provide a 48-hour notice for cancellation of clinical appointments to avoid a missed appointment charge.
______
Client signature Date Counselor signature Date
Please print these forms, fill them out, and bring them to your first therapy session. Thank you.