Client Information Form -Adult
Date: ______
If you have been here before, please provide only the information that has changed.
Ø Identification:
Name: ______Date of Birth: ______Age: ______
Nickname or preferred name: ______Social Security #: ______
Home Address: ______Apt. number: ______
City: ______State: ______Zip Code: ______
Home phone: ______Ok to leave a message?: ______email: ______
Calls and emails will be discreet, but please indicate any restrictions: ______
Ø Referral: How did you hear about my services?
Name: ______Phone: ______
May I have your permission to thank this person for their referral? □ yes □ no
Ø Medical Care: From whom or where do you get your medical care?
Clinic/doctors name: ______Phone: ______
If you enter into treatment with me for therapeutic services, may I tell your medical doctor so that he or she can be fully informed and we can coordinate your treatment? □ yes □ no
Ø Employment:
Current employer: ______Address: ______
Work phone: ______How long have you worked here? ______
Ø Household Income: Please indicate the total gross monthly income range of your household.
Less than $3,000 $3,000-$5,000 $5,000-$10,000 more than $10,000 per month
Ø Education and Training:
Date / School / Adjustment to School / Did you graduate?Ø Family History
Relative / Age (or at death) / Name / Mental Illness / Education / OccupationFather
Mother
Step-parents
Grandparents
Uncles/Aunts
Brothers/Sisters
Ø Marital Relationships
Spouse’s Name / Their age at Marriage / Your age at Marriage / Your age at Divorce/Widowed / Reason for Ending? / How well did you adjust?
1.
2.
3.
Ø Significant Non-Marital Relationships
Name / Their age when started / Your age when started / Your age when ended / Type of relationship / Current State/Adjustment if ended1.
2.
3.
Ø Children (Please indicate children from a previous relationship in column p)
Name / Age / Sex / School / Grade / Adjustment issues? / PØ Family Relationships (Please briefly explain the following):
1. Your parents’ relationship with each other: ______
______
2. Your relationship with each parent and other adults present in the home during childhood: _____
______
3. Your relationship with your brothers and sisters in the past and present: ______
______
4. How do you get along with your spouse or partner? ______
______
5. How do you get along with your kids? ______
______
Ø Religious and racial/ethnic identification:
Religious affiliation: Protestant Catholic Jewish Islamic Native American Pagan
Other (specify) ______
Involvement: None Some/irregular Active
How important are spiritual concerns in your life?______
Ethnicity/national origin: ______Race: ______
Other ways or groups with whom you identify yourself or consider important: ______
______
Ø Abuse History: I was not abused in any way. I was abused.
Types: P=physical (beatings) S=Sexual (touching, molesting, fondling, intercourse) E=emotional
(humiliation, ect.) N=Neglect (failure to feed, shelter, protect)
Your age? / By whom? / Type / Effects on you? / Did you disclose to anyone? / Consequences of disclosing?Ø Chemical/Substance Use:
1. Have you ever felt the need to cut down on drinking/using? ______
2. Have you ever felt annoyed by criticism or complaining about your drinking/using? ______
3. Have you ever felt guilty about your drinking/using? ______
4. How much beer, wine, or liquor do you consume each week on average? ______
5. Have you, at times, drank/used until unconsciousness or run out of money as a result? ______
6. How much tobacco do you smoke, dip, or chew each week? ______
7. Have you ever used inhalants (“huffing”) such as glue, gas, paint, ect? ______
8. Which other drugs (not medications prescribed) have you used in the last 10 years? ______
______
Please provide details about the use and effects of these drugs (amounts, how often used, related problems): ______
______
Ø Treatment History:
1. Have you previously received psychological, psychiatric, drug/alcohol, or counseling services?
yes no If yes, please indicate:
When? / Treatment Provided by? / Presenting Problem? / Outcome?2. Have you previously been prescribed medications for emotional or psychiatric problems?
yes no
Please list previous medications and the prescriber: ______
______
Please list which, if any, were helpful: ______
Ø Self-Injury History:
Have you ever made attempts or tried to purposely end your life? yes no
When? / Reason? / Results? / Medical InterventionsHave you ever intentionally injured yourself when not attempting to commit suicide?
yes no Type: cutting burning pinching hitting puncture/piercing
Ø Legal History
1. Are you required by court, probation/parole officer to have this appointment? yes no
If yes, please explain (include present offense): ______
2. Is the reason for coming related to an injury or accident? yes no
If yes, please explain: ______
3. Have you ever or are you currently in the process of suing anyone? yes no
If yes, please explain: ______
History of offenses: Under jurisdiction use the following code: F=federal, S=state, C=county, Ci=city. Under Sentence write in type of sentence you served, are serving or have to serve (P=probation, CS=community service, F=fine, I=incarceration, Po=parole, R=restitution)
Date / Charge / Jurisdiction(F,S,C,Ci) / Sentence
(P,CS,F,I,Po,R) / Probation/Parole Officer’s Name / Attorney’s Name
4. Will I be contacted by your attorney? yes no Attorney’s name? ______
5. Will I be contacted by your probation/parole officer? yes no
6. Are there any other legal involvements I should know about? ______
______
Ø Other:
Is there anything else you feel that is important to know about that has not been addressed on any of these forms? If yes, please tell me about it here or on another sheet if necessary. ______
______
Ø The Problem: In your own words, please briefly tell me what brings you to my office.
Please include what you feel is the problem, symptoms that tell you that this is a problem, and how/what you have tried before contacting me: ______
______
♦ This is a strictly confidential patient medical record. Reproduction, disclosure, or transfer is expressly prohibited by law.