Client Name:

Name of parent/guardian (if under 18yrs):

Birth Date:

Age:

Address:

Cell Phone:

Home Phone:

E-mail:

Emergency Contact(email):

Phone:

Referred by (if any):

Education:

Occupation:

How Long:

Marital/Relationship Status:

How Long Together:

On a scale of 1-10, how would you rate your relationship?

Significant other’s name/age:

Names & Ages of Children

PRIMARY REASON FOR THERAPY

Explain :

GENERAL AND MENTAL HEALTH INFORMATION

1. What specific life changes or stressful events are you experiencing?

2. Please list any sleep problems you are experiencing and how many hours of sleep you get a night.

3. How many times a week do you exercise?

4. Please list any difficulties you experience with your appetite or eating patterns.

5. How much and how often do you drink alcohol?

6. How much and how often do you engage in recreational drug use? Name of drug ?

7. Have you received or are you currently receiving psychiatric or psychotherapy services? Name of current or past
Provider.

8. Are you currently taking psychiatric medication? Please specify type and dosage

9. Have you ever been given a mental health diagnosis? Please specify diagnosis

10. Please list any specific health problems you are currently experiencing :

FAMILY MEDICAL & HEALTH HISTORY

In the section below, identify by checking the box, if you or a family member
has a history of any of the following issues. Please indicate the family
member’s relationship to you in the space provided (father, grandmother,
Uncle, etc.).

Family Member

Alcohol/Substance AbuseDepressionAnxietySchizophreniaDomestic ViolenceEating DisorderSuicide Attempts

Patient

Alcohol/Substance AbuseDepressionAnxietyBipolar DisorderSchizophreniaDomestic ViolenceEating DisorderSuicide Attempts