Biographical Information Intake Form

Liza J Alvarado, MS, LPC

Biographical Information – Intake Form

Please fill out this biographical background form as completely as possible. It will help me in our work together. Information is confidential as outlined in the Office Policy form and the HIPAA Notice of Privacy Practices. If you do not desire to answer any question, merely write, "Do not care to answer." Please print or write clearly and bring it with you to the first session.

Client Name:______male female

DOB: ______

Parents/GuardianName (if client is minor)______

______

Address:______

City, Zip______

Home Phone:______May I leave a message? __Yes __No

Cell Phone:______May I leave a message? __Yes __No

Email:______

*Email and text are not guaranteed to be a confidential method of communication.

EMERGENCY CONTACT

Name: ______

Relationship to you______

Phone number ______

Address ______

How did you hear about me?______

Reason for seeking counseling services? ______

______

______

Are you currently employed and/or in school? If yes, where/grade/attendance issues.

______

______

Marital Status: Single In a relationship Cohabiting Married Separated Divorced Widowed

Any children/ ages: ______

Who lives with you?______

______

How would you rate your relationships? (with parents, partner, kids, friends) ______

______

______

______

Have you experienced any life changes or stressful events recently? ______

______

______

______

Are you currently experiencing overwhelming feelings of sadness, grief, or depression?

__No

__ Yes; around when did it start: ______

______

______

Are you currently experiencing extreme feelings of anxiety, panic attacks, or any phobias?

__No

__Yes; around when did it start: ______

______

______

Do you have any trouble falling and/or staying asleep? ______

______

Have you received mental health services in the past?

__No, this is my first time.

__Yes, previous therapist/service and when: ______

______

Are you currently taking any psychiatric mediations (for depression, anxiety, etc.)

__No

__Yes, medication/dosage/prescribing physician:______

______

______

Did you take any psychiatric medications in the past? ______

______

Have you ever been hospitalized for psychiatric reasons? ______

______

Name of physician ______

When was your last physical? ______

Do you have any current medical problems? ______

______

______

Please list all illnesses, accidents, injuries, operations and approximate dates:

______

______

Do you drink alcohol, smoke cigarettes, or use any other substance? __No

__Yes; specify which substance and how many times per week.______

______

Do you have trouble controlling your temper? ______

Have you ever been in trouble with the law or had trouble in relationships because of it was hard to control your anger? ______

______

How much time do you spend on social media, websites, apps, etc?______

______

Family History

Please CircleList Family Member(s)

______

Alcohol/Substance Abuseyes/no

Anxietyyes/no

Depressionyes/no

Domestic Violenceyes/no

Eating Disordersyes/no

Obsessive Compulsive Behavioryes/no

Schizophreniayes/no

Suicide/Attemptsyes/no

What do you do to release stress? ______

______

______

Do you practice anything to get inner strength? (meditation, church, being in nature, etc.) ____

______

What are some of your strengths? ______

______

What are some of you weaknesses? ______

______

What would you like to get out of attending therapy? ______

______

______