John W Millikin, PhD, LMFT, PLLC
INFORMATION FORM
Client’s name: ______Date: / /
Gender:______Date of birth: / /
Address: ______
City:______State: ______Zip:______
Phone (home): OK to leave msg? Y N Phone (other): OK to leave msg? Y N
Highest Level of Education: ______
Current Profession: ______Current Employer: ______
Primary reason(s) for seeking services: ______
Marital Status (more than one answer mayapply):
__Single __Divorce in process __Unmarried __living together __Legally married __Widowed
Assessment of current relationship (if applicable): □Good □ Fair □ Poor
Who is living at current residence? (Please list names andages):
Children not living in the home? (Please list names and ages):
Family Mental Health History:
Has anyone in your family including yourself experienced difficulties with the following?
(Check any that apply and listfamily member, e.g., Sibling, Parent, Uncle, Self, etc.):
Depression: □ No □ Yes
Bipolar Disorder: □ No □Yes
Anxiety Disorders: □ No □Yes
Panic Attacks: □ No □ Yes
Schizophrenia: □ No □Yes
Alcohol/Substance Abuse: □ No □Yes
Eating Disorders: □ No □Yes
Learning Disabilities: □ No □Yes
Trauma History: □ No □ Yes
Suicide Attempts: □ No □Yes
Substance Use: Do you currently use or have you used the following substances.If yes please describe frequency, amount, time of first use, and any current use(within the last 30 days):
Cigarettes: □ No □ Yes Caffeine: □ No □ Yes Alcohol: □ No □ Yes
Street Drugs: □ No □ Yes Prescription Medication (not as prescribed): □ No □Yes
Have you ever been concerned for your partner in any of the above areas?□ No □ Yes
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Medical/Physical Health (please check all that apply and providefurther explanation in the space provided ifnecessary:
□ Dizziness/Fainting
□ Epilepsy
□ Sexually transmitted diseases
□ Allergies
□ Eating problems
□ Sleeping problems
□ Anemia
□ Fatigue
□ Hearing problems
□ Heart Problems
□ Vision Problems
□ Autoimmune Disease
□ Digestive Issues
□ Neurological Issues
□ Reproductive Issues
□ Other Current Medications (please list both prescription and over the countermedication as well as dose, frequency, and reason for medication):
Please list and medical, mental health, or other professionals I should speak within order to provide you with comprehensive services:
Name:______Phone:______
Name:______Phone:______
Development: Are there special, unusual, or traumatic circumstances that affected your development? □ Yes □ No
If Yes, pleasedescribe:
Has there been history of trauma or abuse as a child or an adult? □ Yes □ No
If Yes, please share as much as you are comfortable sharing in the space provided:
Military experience?: □ Yes □ No If Yes,describe:
Please describe previous experience with counseling including what was helpful and what was not helpful:
Anything else that you believe it is important that I know?