Client Information
Name:
Steet Address:
City:	State:   Postal Code:
Country:
Date of Birth:
Day Phone Number:	Night Phone Number:
Email Address:

 

In Case of Emergency
Emergency Contact Name:
Telephone/Cell Number:
Relationship to you:

 

Requested Service Information
What concern has prompted you to contact me at this time?
Have you had prior counseling?	Yes  No
Is a therapist, counselor or psychiatrist treating you now?	Yes  No
If so, when and with whom?

 

Medication, Alcohol, Drug History
Please list all medications you are currently taking and dosages:
Do you drink alcoholic beverages?	Yes  No
If so, which alcoholic beverages?
If so, please indicate frequency and amounts:
Do you use drugs?	Yes  No
If so, which drugs?
If so, please indicate frequency and amounts:
Do you have a family history of alcohol  or drug abuse or other addictions?	Yes  No
What is their relationship to you?
Do you have a family history of mental illness?	Yes  No
If so, what is their relationship to you?
Have you ever been hospitalized for drug or alcohol abuse,  a suicide attempt, nerves, or other mental concern?	Yes  No
If so, please indicate when and where:

 

Relationship and Family History
If you are married or have a significant other or  long-term partner, how long have you been together?
Please describe the relationship:
Do you currently have any thoughts or  feelings of wanting to physically harm yourself?	Yes  No
If so, do you have a plan to do so?	Yes  No
Do you currently have any thoughts  or desire to harm someone else?	Yes  No
If so, please tell me something about this:
If you have children, please list their names and ages:
Are your parents living?	Yes  No
If not, please indicate age and cause of death:
If you have brother or sisters, please list names, ages and occupations:
Who lives in your household with you and what is their relationship to you?

 

Education and Employment History
How much education do you have?
Please list degrees completed, name of institution and dates of completion:
Are you currently a student?	Yes  No
If so, what are you studying and which school do you attend?
If you are currently a student, how are your grades and how do you like school?
With whom are you currently employed?
Please provide name and address of your place of work:
Are you happy with your current career/job?	Yes  No
If not, why?
Please list your employment history starting with your current job:
Have you served in the Armed Forces?	Yes  No
If so, please indicates dates and positions held:

 

Personal History
Please describe any medical history you feel is affecting your well-being:
Have you ever been physically or sexually abused,  or do you worry that you might have been?	Yes  No
If so, by whom and how old were you?
Are you experiencing any sleep difficulties?	Yes  No
If so, please describe:
Have you ever had an eating disorder?	Yes  No
If so please describe:
Have you experienced any recent  significant weight gain or loss?	Yes  No
How would you describe your appetite?
Have you ever been arrested or convicted of a crime?	Yes  No
If so, please indicate dates and disposition of charges:
Is there anything else about you I should know?

 

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