Adult Client Information and History
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Month
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Client Name
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First Name
Last Name
Date of Birth
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Year
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Welcome to counseling! Please help your counselor get to know you by filling out this form.
What made you contact us, and what do you hope to achieve?
Have you had counseling before?If so, please describe the purpose, how long it lasted, and what you gained from it. If you have had a disappointing counseling experience in the past, please describe how it disappointed you.
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NEXT - Family and Growing up years
FAMILY AND GROWING UP YEARS
Are you
Single
Married
Significant relationship
Other
If you are in a relationship, please describe it and how things are going.
If you have kids, what are their names and ages?
Whom, if anybody, do you currently live with?
Please list your parents, including significant stepparents or parenting figures. Please let us know if they are still living, or have passed away:
Please list your siblings, including step-siblings, in birth order:
In one or two sentences, please describe your childhood:
What, if any, are your spiritual/religious affiliations and beliefs?
How important is it to incorporate your spiritual practices into counseling?
Please Select
Not at all important
Somewhat important
Very important
Are there any family or cultural norms or issues that you would like to address in order for your counselor to better understand your needs or background?
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NEXT - Health
HEALTH
What medical challenges do you currently have?
What prescription medications do you currently take?
How much alcohol, if any, do you drink?
Which recreational drugs, if any, to you take, and how much?
How much tobacco, if any, do you use?
How well do you sleep?
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NEXT - Work and Money
WORK AND MONEY
What do you do for a living?
On a scale of 1 to 5, how much do you like your job?
Don't like it at all
1
2
3
4
Really like it
5
1 is Don't like it at all, 5 is Really like it
On a scale of 1 to 5, how stressful is your job?
Very stressful
1
2
3
4
Not stressful at all
5
1 is Very stressful, 5 is Not stressful at all
Do you feel you have enough money to be comfortable?
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NEXT - Well-Being
WELL-BEING
Have you ever been so sad you thought of harming yourself or taking your life? If so, please share when, and what the circumstances were.
Have you ever seriously thought of harming someone else? If so, please share when, and what the circumstances were.
What do you worry about?
What do you worry about?
What are your hopes and dreams?
Please check all that apply
Depressed mood
Low self esteem
Self loathing/hatred
Suicidal thoughts
Suicidal action/attempts
Self-harm/cutting
Feelings of hopelessness
Always Tired/over sleeping
Feel “stuck” / dissatisfied in life
Teary/ emotional
Unable to have a good time
Recurrent Dreams/nightmares
Significant weight loss/gain
Hear or see things others don’t
Difficulty making decisions
Anxious Feelings
Feel Tense/panicky
Always Worried
Fears and/or Phobias
Obsessive thoughts
Compulsive acts
Unable To Relax
Insomnia
Drugs/ Alcohol issues
Recovering addict/alcoholic
Difficulty expressing emotions
Relationship issues
Sexual issues
Gender distresses
Sexual orientation concerns
Difficulty making/keeping friends
Social fears
Manic/hyper episodes
Gambling issues
Anger issues
Binge / over-eating
Restrict eating/induce vomiting
Bad home/living conditions
Past/current abuse or trauma
Grief/loss
Financial concerns
Job concerns
Parenting parent-child concerns
Family issues
Other
Other
What else would you like us to be aware of?
Client, Parent or Guardian Signature
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