CLIENT CONFIDENTIAL INFORMATION PACKET

CLIENT CONFIDENTIAL INFORMATION PACKET
Initials of Client
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Client Name

First NameLast Name
Your therapist
Your Email
example@example.com
The main reason I came for counseling at this time:
If married, in addition to putting a check mark next to all the issues that concern you, please also put a check next to issues that pertain to your spouse.

Individual Concerns:

Relationship Concerns:

Other relationship concerns:
Infant History: (0–2) (prenatal experience, delivery traumas, early illnesses, significant events)
Childhood History (2 - 6 ) (developmental milestones, significant events, relationships, how I felt about myself and others)myself and others
School History: (6–12) (first days, attendance, achievement, significant relationships, perception of school)
Adolescent History: (12–18) (social relationships, sexual development, dating, significant memories)
Adulthood History (18 +) (academic pursuits, vocational training, career directions and goals, marriage and family life, significant memories)
Please check off and explain if any of the following applies to you or a family member:

Explain

Rows	Check All that apply
Take time for myself
Spend time outdoors with nature
Meditate regularly
Attend a public worship in my denomination
Regularly involve myself in physical exercise
Regularly read and develop myself spiritually or psychologically
Feel like I can tackle challenges that surround me
Have one or more deep intimate friends
Am involved with a group of friends recreationally
Eat three healthy meals a day
Sleep soundly and regularly
Do not smoke
Do not drink to excess or have more than three drinks per week
Handle stress well
Review my life goals
Am not overweight

Sentence Completion

Rows	Person	Problem (date and severity)
Alcohol
Drugs
Other medications
Diseases
Significant accidents including head injury
Pregnancies/ miscarriages
Sleep Apnea/ Insomnia
Depression/Bipolar/ Seasonal Affective Disorder
Anxiety
Hospitalization*
*If hospitalized, indicate if psychiatric
Outpatient care or therapy**
**Indicate if outpatient care was psychiatric
Other

Family History