New Client Form (Adult) Date

Northeastern Professional Counseling

New Client Form (Adult) Date:

Instructions: Please complete this form to the best of your ability with the information you have available to you at this time. Do your best to answer each item as fully as you can.

General Client Information

Name: (First, Middle, Last)Gender: Age: DOB: Soc #:

Address City State: Zip code:

Home Phone: Cell: May we leave you a voice message? YES NO

Email address: (please be aware email is non-secure)Place of Birth:
Ethnic/Cultural Background: Religion: Native Language: Marital Status: Education (highest degree/grade/level): Occupation: Annual Income: Employer: Emergency Contact: Relationship: Phone:

Are you comfortable having an intern currently working at NPC (supervised by Anna) sit in your session(s) for teaching/learning purposes? Yes No

Referred by: May I thank this referral source for directing you to this practice? Yes No

Health Insurance Information

Insurance Company: Policy #: Group #: Co Pay:

Name of Subscriber: Date of Birth of Subscriber: Relation to Client:

Place of Employment of Subscriber: Primary Care Physician (Doctor’s Name):

Primary Care Physician Contact Info: Physician NPI (Office Use):

Current Issues

Please provide a brief description of why you are seeking counseling/therapy services at this time:

Has anything happened that may have brought on/intensified the problems you are experiencing? Yes No If yes, please explain:
When (month/year) did you first begin to experience these problems?

How many days, weeks, months, or years have you been experiencing these problems?

How often do you experience these problems? (check the one that best describes your current experience).

Most of the day, every day

Some part of the day, every day

Most of the day on most days

Some part of the day on most Days

More than once a week

More than once a month

Other:

How much is/are the problems affecting you? Mildly Moderately Severely

In what areas do your problems impact your life? (Check all that apply)

Lifestyle (the way you live your life)

Activities (things you normally do or would like to do)

Relationships (your ability to form or maintain relationships with others)

Sleeping

Mood

Have you ever attempted suicide? Yes No If yes, when?

Have you been thinking about suicide? Yes No

Have you ever thought about harming or killing someone else? Yes No If yes, when?

Have you been thinking about harming or killing someone else? Yes No

Adult Problems Checklist

Instructions: Please check all that apply to you

Northeastern Professional Counseling

Emotional Issues:

Depression

Anxiety/tension/worry

Stress

Anger/frustration

Loneliness

Feeling Ignored or

abandoned

Mood swings

Lack of interest/enjoyment

in life

Feeling hopeless

Feeling worthless

Feeling guilty

Feeling shameful

Feelings of sadness/loss

Easily irritated/annoyed

Grief/bereavement

Feeling “hyper”

Bodily Issues:

Low energy

Panic attacks

Chest pain or heaviness

Heart racing

Weight problems

Appetite changes

(more/less)

Sleep changes (more/less)

Bad dreams/nightmares

Chills/hot flashes

Tingling/numbness

Nausea

Northeastern Professional Counseling

Pain

Health problems

Feeling “not real”

Feeling detached from

yourself

Thought Issues:

Poor concentration

Fear of dying

Fear of going “crazy”

Fears or phobias

Obsessions/compulsions

Thoughts racing

Low self-esteem

Self-criticism

Can’t hold onto an idea

Suspiciousness or

mistrustfulness

Delusions/hallucinations

Confusion/can’t think clearly

Losing track of time

Problems with memory

Unpleasant thoughts that

won’t go away

Bothered by recurring

thoughts

Behavioral Issues:

Isolating from others/social

withdrawal

Disorganization

Aggressiveness

Perfectionist behavior

Lying

Procrastination

Impulsiveness

Excessive behaviors

(Examples: spending,

gambling, sex, alcohol)

Self injurious behaviors

Job/career problems or

indecision

Financial problems

Stealing

Use of alcohol

Use of drugs

Blackouts

Trouble with the law

Destruction of property

Strange, weird, or peculiar

behavior

Performing unusual ritual or

habits

Relational Issues:

Family problems

Marital/relationship

problems

Parent/child problems

Problems trusting others

Loss/death of someone

Making/keeping friends

Arguing with others

Shyness

Social skills

No/lack of social support

(family/friends)

Sexual problems

Your problems impacting

others

Trauma:

Physical abuse

Sexual abuse

Partner abuse

Experienced/witnessed

trauma

Other (please describe):

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Current Life Experiences

I live in: Apartment House Condo/Townhouse Mobile Home Rooming House Other

Person(s) Living in your home / AGE / Significant Issues

Other significant persons in my life who do not live with me include:

Name Age Relationship/Problems

Problems or changes in my family or other important interpersonal relationships:

Date(s) Persons Involved Problems or Changes

Problems or changes in occupational, educational, social, or recreational functioning:

Date(s) Where did this occur? Problems or Changes

What makes you feel good about yourself at the end of a day:
What weighs on your mind a lot:

What do you do to relax/have fun:
Do you have any current/long term goals:

What I hope to gain from counseling/therapy:
My typical day is as follows:

History of Counseling or /Therapy

Are you currently being treated by a counselor, psychologist, or psychiatrist? Yes No
If yes, please provide the following information:

Date(s) Name of ProfessionalTreatment Type (counseling, therapy, medication, etc.)

Please provide information regarding previous treatment you have received from a counselor, psychologist, psychiatrist, or other medical or mental health professional for this or other problems:

Date(s) Name of Professional Treatment TypeWhy treatment ended

Have you ever been hospitalized for treatment of an emotional or mental disorder? Yes No

If yes, please provide the following information:

Date(s) Name of Hospital or FacilityReason for Hospitalization

Medical History

Please complete the information below regarding past and currentmedical conditions and treatment:

Date(s) Physician Name Condition Treatment/Results

Please list any hospitalizations or surgeries:

Date(s) Hospital/Facility Condition/Type Treatment

Please list all current prescription and over the counter medication use:

Begin Date: Medication/DoseFrequency of use Condition Treated

Please list any previous prescription and over the counter medication use significant to your counseling/therapy:

Date(s) Medication/Dose Frequency of use Condition Treated

From: To:
From: To:
From: To:
From: To:
From: To:
From: To:

Please list any allergies/sensitivities/drug reactions:

Current/History of Drug Use

Ever Used? / Substance
Age of 1st Use / Pertinent Information- i.e. frequency of Use/Current/Past
Y N / Tobacco: Smoking
Chewing
Y N / Alcohol
Y N / Prescription Drugs
Y N / Marijuana
Y N / Cocaine/Crack
Y N / Heroin, speedball
Y N / Methamphetamine
Y N / Sedatives or tranquilizers (downers)
Y N / Stimulants (uppers, speed, ice)
Y N / Hallucinogens (PCP, angel dust, ecstasy, mushrooms, LSD)
Y N / Sniffed or inhaled anything to get high (poppers, sprays, glue)
Y N / Other:

Family of Origin

Please describe the background or status of your family of origin for the following categories:

Ethnic: Social: Religious: Financial:

Briefly describe any of the following that apply to your family of origin:

Crisis or other significant events:

Any emotional, psychological, or physical illness: (Examples: cancer, diabetes, heart disease, depression, alcoholism, drug abuse or addiction, family violence, depression, suicide)

Communication styles in your family of origin? Who did most of the talking, teaching, and connecting?

Please Describe past and current relationship with:

Mother:

Father:

Stepparent: or N/A

Siblings: or N/A

Other significant family members:

For Office Use Only:

Diagnosis and Summary

Including co-occurring disorders or relevant medical diagnoses

Code Number / Type
Principal (P) or
Additional (A) / Description
P A
P A
P A
P A
P A
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Types of Problems: Primary support group Social environment Educational Occupational Housing Economic Access to health care services Interaction with legal system/crime Other psychosocial and environmental problems:
GAF Score:

Recommendations:

Signature/Credentials: ______Date: ______