Client Demographic Sheet
We request this information so that we may know about you and be better able to serve you; however, if there are any questions that you do not wish to answer, you are not obligated to do so.
GENERAL INFORMATION
Date:______Name:______
Social Security #______
Address:______City______State____Zip______
Home Phone:______Business Phone______
Age:______Date of Birth:______Sex:______
EMPLOYMENT
Occupation:______Employed by:______
No. of dependents:______Total household income:______
Is your occupation what you want to be doing? Yes/No
If not, what is your ideal occupation?______
EDUCATION
Years of education completed: 1 2 3 4 5 6 7 8 9 10 11 12 (Circle highest year)
College 1 2 3 4 Degree obtained:______
Graduate School Degree obtained:______
RELIGION
Denomination:______Church Affiliation:______
Pastor/Priest/Rabbi:
What, if anything, would you like to say about your faith?
ACCDOC100909
MARITAL STATUS
Single__Engaged__Living together__Married__Widowed__Separated___Divorced___
Number of times married:______
Date(s) of marriage(s):______
Date(s) of divorce(s):______
Date(s) of death of mate(s):______
MATE:
Name:______Age:___
Address______Phone #______
Occupation:______Employed by:______
CHILDREN
Name Age Sex Descriptive Words
FAMILY HISTORY
Mother Father: ______
Living (if yes, age): ______
Education/Occupation:______
Number of times married:______
Emotionally closer to:______
Descriptive words:______
If parents are separated___, divorced___, or deceased___, what was your age at that Event?____
What is/was your greatest difficulty with your parents?______
______
In your family, you are ______in birth order of ______children.
PROBLEM OR STRESS INFORMATION
What are you experiencing and/or what has happened to cause you to seek counseling?
______
______
______
ACCDOC100909
Have you had previous counseling/psychotherapy? Yes/No If yes, date(s)______
Issues addressed:______
What do you wish to change in your life?______
______
How do you expect Absolutions Counseling Center to assist you in making that/those Change(s)?______
______
______
GENERAL HEALTH
How would you rate your general physical health? Excellent__Good__Fair__Poor__
Are you under the care of a physician?Yes/No If yes, please name______
Please explain why______
When was your last physical examination?______
Please list medication(s) taken regularly______
Do you exercise Yes/No How often?______
List past major emotional &/or physical difficulties you have experienced (please also give date(s): ______
Do you drink alcohol? Yes/No How often?______
Do you take any non-prescribed &/or illegal substances? (If yes please list)______
ACCDOC100909