Carolyn Aibel, Ph.D., Licensed Clinical Psychologist
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CLIENT INFORMATION SHEET
Today's Date:
/
Month
/
Day
Year
Date
Name:
Name of parent/ guardian (if applicable):
Address:
Email address:
Phone numbers:
Parent/ guardian's phone number (if applicable):
Where do you prefer I call?
Home
Cell
Work
May I leave a message identifying myself?:
Yes
No
Date of birth:
/
Month
/
Day
Year
Date
Occupation:
Referred by:
Physician's name:
Emergency contact:
Legal name of person responsible for payment:
SS # of person responsible for payment:
What do you hope to gain from therapy:
Which of the following issues are you currently experiencing or have you experienced in the past:
Current
Past
Abuse/ Neglect
Alcohol/ Drug Abuse
Anxiety
Body Image Issues
Chronic Pain
Depression
Domestic Violence
Eating Issues
Grief
Hallucinations
Parental Divorce
Sexual Concerns
Sleep Issues
Suicidal Thoughts
Suicide Attempts
Weight Issues
For any symptoms/ events you checked, please write details here:
What is the current composition of your intimate relationship/ family? (include names, ages, and occupations)
What was the composition of your family while you were growing up (if different from above answer):
Please list any significant losses, traumas, or issues during your childhood:
How many days a week do you drink alcohol:
0
0
1-2
3-4
5-6
7
How many drinks do you have in a typical week:
0
1-2
3-4
5-6
7-8
9-10
10+
How often do you smoke marijuana:
Never
< 1x a week
1x a week
2 x a week
3-4 x a week
5-6 x a week
Every day
What other recreational drugs are you using if any and how often:
Please list any previous psychotherapy treatment if any (therapist names and approximate dates):
What medications are you currently taking and what have you taken in the past? (Please indicate what medication is/ was treating.)
Is there anything else that you would like me to know?
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