CLIENT INFORMATION – CONFIDENTIAL
Date: ______Name: ______Birth date: ______Age: ______
Address: ______City______State:_____ Zip: ______
Phone numbers: Home: ______Work: ______Cell/Other:______
Can I contact you at home? Y N Work? Y N Can I leave you messages at home? Y N
Can I mail information to you at the address provided above? Y N
Can I email information to you? Y N Email address: ______
Occupation: ______
Primary Care Physician: ______Phone#: ______Date of last visit: ______
Other health care providers: ______Phone#:______Date of last visit: ______
______Phone#:______Date of last visit: ______
Please list any prescription medications you are taking:
Medication Dose/Frequency Reason Date began Prescribing Dr.
______
______
______
______
______
Have you been in psychotherapy ?______If yes, with whom:______When?______
Concerns addressed: ______
Was it helpful? ______
□ Psychology Today □ Internet Search □ Insurance/EAP□ Friend/Colleague □ AAMHP Directory □ Other______
Do you belong to a religious or spiritual congregation? If yes, where? ______
In case of an emergency, who would you like notified?
Name______Relationship to you:______Phone#:______
Address: ______
List persons living in your home:
Name Age Relationship to you Occupation
______
______
______
______
______
Do you have other children not listed above? What are their names and ages?
______
______
It is very helpful to your therapy if I have certain important information at the beginning. Please do your best to answer the following. If you are unwilling to do so at this time, we will be able to discuss any concerns you might have.
In an average week, how often do you use:
Alcohol ______how much______Marijuana______how much______
Other______how much______Other______how much______
Other______how much______Other______how much______
Does a family member or anyone you are living with have an alcohol or drug problem?
______
Is there verbal abuse or physical violence of any kind in your home?
______
Are you having any thoughts of killing yourself?
______
Are you having any thoughts of physically hurting another person?
______
Have you had any suicidal thoughts, plans, or attempts in the past?
______When? ______
Have you ever been hospitalized? ______When? ______
For what reason? ______
Have you been Court-ordered to have counseling? ______
Are there any issues not covered above which concern your situation?
______
______
Why are you seeking therapy at this time?
______
What do you hope to gain from therapy?
______
If client is under the age of 18, please complete the following information:
School: ______Grade:______
Parent/guardian: ______Birth date:______
Address: ______City:______State:______Zip:______
Home Phone: ______Work Phone: ______Cell Phone: ______
Occupation: ______Relationship to child: ______
School: ______Grade:______
Parent/guardian: ______Birth date: ______
Address: ______City:______State:______Zip:______
Home Phone: ______Work Phone: ______Cell Phone: ______
Occupation: ______Relationship to child: ______
Custody Status: ______
NOTE: If separated or divorced, I will need a copy of the court document indicating your child’s current
custody status in order to provide treatment.