CLIENT INFORMATION
The information requested in this form will be kept confidential, and will help your counselor to assist you. Please fill out the form as completely as you can. Use an “x” to indicate your choices. Write in words or numbers where asked.
GENERAL INFORMATION
Last Name ______First Name ______Middle Initial _____
Birth Date ______Social Security # ______ Male Female
Street Address ______Apt. # ______
City ______State ______Zip ______
Home Telephone ( ) ______Work Telephone ( ) ______Other # ______
Guardian/parent (if under 18)______
Referred by: ______
Reason for Referral ______
Reason for choosing this Center______
Religious/denominational preference______
Your congregation/church/temple ______
Your racial/ethnic identity: African-American Native-American Asian American
White/Caucasian Hispanic Other
______
EMPLOYMENT/EDUCATION INFORMATION
Full time employee ____ Full time at home____ Part-time employee ____ Unemployed ____
Place of Employment ______
Type of work you do ______
Highest Level of Education Completed: High School College degree Graduate Degree
Professional training Other ______
______
FAMILY INFORMATION
Relationships: Single Engaged Married Separated Divorced Widow(er) Cohabitating
Parents: Mother: living, age ____ Deceased Father: living, age ____ Deceased
SiblingsNumber of Brothers ____ Number of Sisters ____ Only Child
List ages of Brothers ______of Sisters ______
Names and ages of your children ______
______
Have any of your children died ? ______
______
LEGAL HISTORY
Do you have any current or past legal records such as arrests, litigations, bankruptcies?
Yes No
CLIENT INFORMATION (Page 2)
PROBLEM DEFINITION (You can complete any questions on the back)
What is your reason for seeking help now? ______
______
Are any of the following a problem for you at this time? (Check the ones that apply)
___ Anxiety ___ Guilt ___Concentration
___ Grief___ Suicidal Feelings___ Decision making
___ Depression___ Hopelessness___ Sleeping
___ Irrational fears___ Rage___ Appetite
___ Nervousness___ Relationship to parents___ Physical health
___ Loneliness___ Relationship to children___ Traumatic experience
___ Anger___ Loss of meaning of life___ Other (list)
___ Marriage problems___ Loss of faith in God ______
___ Sexual problems___ Work issues______
___ Self esteem___ Religious doubts ______
___ Stress___ Aging ______
___ Substance abuse___ Mid-life ______
What would you like to see happen as a result of psychotherapy or counseling?
______
______
MEDICAL/PSYCHOLOGICAL HISTORY
Name and address of your physician:______
______
When was your last medical examination?______
Are you suffering any physical illnesses or symptoms at this time?______
______
List major surgeries or illnesses in the last five years: ______
______
______
List current medications:______
______
Have you or any member of your family received help for drug or alcohol dependency?
Yes NoWhen? ______Name of helping agency ______
Have you received psychotherapy or counseling in the past? Yes No When?______
Name of treating therapist: ______
Make a check mark if any of these statements are true:
I have thoughts of harming myself or others.
My thoughts of harming myself are frequent.
I dwell on these thoughts and wonder if I can control them.
I have sought help because of these thoughts or feelings.