Client Information - Adult
Deep Roots Counseling, LLC
Alicia Brock, MA, LPC
333 W. Drake Rd #141
Fort Collins, CO 80526
720-446-6549
Please fill out this form as fully and openly as possible. All information is held in strictest confidence within legal limits. If certain questions do not apply, leave them blank.
Date: ______
Personal History
1. Legal Name: ______2. DOB:______
3. Preferred Name ______
4. Gender:______5. Preferred Pronouns ______
6. Relationship Status: ___ Married/Partnered ___Single ___ Divorced ___ Widowed
If in a relationship, for how long? ______
On a scale of 1-10 (1=low, 10=high) how would you rate your relationship?______
7. Home Address:______
City:______State:______Zip Code:______
8. Email:______(OK to contact via email? ____Y ____N)
9. Phone: (Home) ______(Cell)______(OK to leave message? ____Y ____N)
10. Person to Contact in Case of an Emergency:______
11. Best way to reach them:______
12. Who lives in the home with you?______
13. Occupation? ______
14. Have you previously been involved in therapy/counseling?___Y ___N
If yes, please describe what worked, what didn’t: ______
______
15. Why have you chosen to come to therapy, now?______
______
16. How long has this issue been going on?______
17. Under what conditions does the issue/problem get worse?______
______
18. Under what conditions does the issue/problem get better?______
______
Medical History
19. Primary Care Physician’s Name:______
20. Physician’s contact information: Address:______City:______State:______Zip Code:______Phone:______
21. Most recent physical exam date:______
22. Results:______
23. Names of other significant health professionals:______
______
24. List any major illnesses and/or operations:______
______
25. List any physical concerns occurring at present: (e.g., high blood pressure, headaches)______
26. List any physical concerns in past: (e.g., head injury, seizures)______
______
27. List any emotional concerns occurring at present: (e.g., crying, fearful)______
______
28. List any emotional concerns in past: (e.g., angry, timid)______
______
29. Do you have a history of psychiatric hospitalizations? _____N _____Y
If yes, where and when?______
30. Do you have a history of suicidal/homicidal tendencies or self – harming behaviors?_____N_____Y Please describe:______
______
31. On average, how many hours do you sleep daily?______
32. Do you have trouble falling asleep at night? _____N _____Y
If yes, how long has this been a problem?______
33. Do you any nightmares or significant dreams? ___N ___Y
If yes, please describe:______
34. Describe your current appetite: _____Poor _____Average _____Large
Is this atypical? _____N _____Y
35. Do you exercise regularly? ___Y ___N Type?______
36. Have you experienced any significant weight changes in the last two months? ______
37. What medications, vitamins, and herbs (and dosages) do you take at present, and for what purposes?______
______
38. Do you drink alcohol? ___Y ___N Frequency? ______
39. Do you smoke cigarettes? ___Y ___N Frequency? ______
40. Do you use Marijuana? ___Y ___N Frequency?______
41. Do you use any other recreational drugs? ___Y ___N Frequency? ______
42. Have you used recreational drugs in the past (include Marijuana)? ___ Y ___ N
Type and frequency? ______
43. Do you drink caffeinated beverages? ___Y ___N Frequency? ______
Behavioral History
44. In the last year, have you experienced any significant life changes or stressors?______
______
45. What do you hope to get out of therapy? ______
______
46. How hopeful are you about your future (1=not at all, 10=very)? ______
47. Are you currently having suicidal thoughts? ___Y ___N
If yes, have you done anything recently to hurt yourself? ___Y ___N
48. Have you had suicidal thoughts in the past? ____Y ____N
If yes, when and how frequently? ______
If yes, have you ever acted on them? ___Y ___N How? ______
49. Do you currently have thoughts of harming someone else? ___Y ___N
If yes, have you acted on them? ___Y ___N
50. Have you previously had thoughts of harming someone else? ___Y ___N
If yes, did you act on it? ___Y ___N Result? ______
51. Are you currently experiencing: Rating Scale 1-10 (10 =worst)
Only rate the areas to which you say “yes”
Depressed Mood or Sadness yesno ______
Irritability/Angeryesno ______
Mood Swings yesno ______
Rapid Speech yesno ______
Racing Thoughtsyesno ______
Anxiety yesno ______
Constant Worryyesno ______
Panic Attacks yesno ______
Phobias yesno ______
Sleep Disturbances yesno ______
Hallucinations yesno ______
Paranoia yesno ______
Poor Concentration yesno ______
Alcohol/Substance Abuse yesno ______
Body Aches/Painsyesno ______
Eating Disorderyesno ______
Body Image Problems yesno ______
Repetitive Thoughts (e.g., Obsessions) yesno ______
Repetitive Behaviors (e.g., counting ) yesno ______
Poor Impulse Control (e.g., ? spending) yesno ______
Self Mutilation yesno ______
Sexual Abuseyesno ______
Physical Abuseyesno ______
Emotional Abuseyesno ______
Social Withdrawalyesno ______
Social Discomfortyesno ______
Boredomyesno ______
Poor Memoryyesno ______
Flashbacksyesno ______
52. Have you previously experienced: Rating Scale 1-10 (10 =worst)
Only rate the areas to which you say “yes”
Depressed Mood or Sadness yesno ______
Irritability/Angeryesno ______
Mood Swings yesno ______
Rapid Speech yesno ______
Racing Thoughtsyesno ______
Anxiety yesno ______
Constant Worryyesno ______
Panic Attacks yesno ______
Phobias yesno ______
Sleep Disturbances yesno ______
Hallucinations yesno ______
Paranoia yesno ______
Poor Concentration yesno ______
Alcohol/Substance Abuse yesno ______
Body Aches/Painsyesno ______
Eating Disorderyesno ______
Body Image Problems yesno ______
Repetitive Thoughts (e.g., Obsessions) yesno ______
Repetitive Behaviors (e.g., counting ) yesno ______
Poor Impulse Control (e.g., ? spending) yesno ______
Self Mutilation yesno ______
Sexual Abuseyesno ______
Physical Abuseyesno ______
Emotional Abuseyesno ______
Social Withdrawalyesno ______
Social Discomfortyesno ______
Boredomyesno ______
Poor Memoryyesno ______
Flashbacksyesno ______
Other Information
53. Are you currently experiencing any financial/legal problems? ___Y ___N
______
54. What role, if any, do religion and/or spirituality play in your life? ______
______
55. Are you satisfied with your social situation/interpersonal relationships? __Y __N
If no, explain why:______
______
56. What do you consider to be your strengths? What do you like most about yourself?______
______
57. What are effective coping strategies you use when stressed? ______
______
58. Is there anything that I did not ask about here that would be important for me to know about you?______
______
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Client Signature Date
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