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Client Information Form
This form is completely confidential
Today's Date
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Month
-
Day
Year
Name
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First Name
Middle Name
Last Name
Date of Birth
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Month
-
Day
Year
Date
Social Security Number (Last four only)
Home Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Name of Employer
Employer Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Home Phone
*
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
Cell Phone
Format: (000) 000-0000.
Email
*
Calls will be discreet, but please indicate any restrictions
Telehealth option: If my primary therapy is face-to-face, but an emergency arises on my part or on the part of the therapist or environmental emergency that inhibits one or both of us from being in the office, I am willing to use telehealth as an alternative for that particular session.
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Yes
No
Referred By:
May I have your permission to thank this person for the referral
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Yes
No
N/A
If referred by another clinician, would you like for us to communicate with one another?
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Yes
No
N/A
Person to notify in case of any emergency
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Emergency Contact Relation to Patient
*
Emergency Contact Email Address
*
example@example.com
Emergency contact phone number
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Format: (000) 000-0000.
We will only contact this person if we believe it is a life or death emergency. Please provide your name to indicate that we may do so
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Please briefly describe your presenting concern(s):
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The following information on this form will help guide your treatment. Please try to fill out as much as you are comfortable disclosing.
What are your goals for therapy?
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The following information on this form will help guide your treatment. Please try to fill out as much as you are comfortable disclosing.
How long do you expect to be in therapy in order to accomplish these goals (or at least feel like you have the tools to accomplish them on your own)?
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The following information on this form will help guide your treatment. Please try to fill out as much as you are comfortable disclosing.
Medical History
Please explain any significant medical problems, symptoms, or illnesses
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Current Medications
Rows
Name of Medication
Dosage
Purpose
Name of Prescribing Doctor
Medication One
Medication Two
Medication Three
Medication Four
Medication Five
Do you smoke or use tobacco?
Yes
No
If Yes, how much per day?
Do you consume caffeine?
Yes
No
If Yes, how much per day?
Do you use any non-prescription drugs?
Yes
No
If Yes, how much per day?
Do you consume alcohol?
Yes
No
If Yes, how much per day?
Has anyone voiced concern about your substance use?
Yes
No
Have you ever been in trouble or in risky situations because of your substance use?
Yes
No
Previous Medical Hospitalizations
Rows
Approx Start Date
Approx End Date
Reason
Hopitalization One
Hospitalization Two
Hospitalization Three
Previous Psychiatric Hospitalizations
Rows
Approx Start Date
Approx End Date
Reason
Psychiatric One
Psychiatric
Two
Psychiatric
Three
Have you ever talked with a psychiatrist or psychologist?
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Yes
No
If Yes, please list approximate dates and reasons
Height
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Gender
*
Age
*
Weight
*
Gender Identity / Preferred Pronouns
Sexual Orientation
Sexuality
Heterosexual
Lesbian
Gay
Bisexual
Transgender
Family
How would you describe your relationship with your caretakers?
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How would you describe your relationship with your father?
Are there any cultural considerations you’d like us to be aware of?
Relationship with mother/caretaker
relationship with father/caretaker
Parent/caretaker's relationship status
*
Married
Divorced
Separated
Widowed
Other
How old were you at the time of separation or divorce?
Were there any other primary care givers who have had a significant relationship with you? If so, please describe how these people may have impacted your life:
*
Number of Siblings
Rows
Number
Ages
Brothers
Sisters
How would you describe your relationship with your siblings?
Social Support, Self-Care, and Education
Currently in a relationship?
*
How long?
Relationship Satisfaction
Worst
1
2
3
4
5
6
7
8
9
Best
10
1 is Worst, 10 is Best
Currently Married/Life Partnered?
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How long?
Previously Married/Life Partnered?
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How long?
Do you have any children
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If yes, how many?
Describe any problems your children are having
List names and ages of those living in your household
Current level of satisfaction with friends and social support
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Worst
1
2
3
4
5
6
7
8
9
Best
10
1 is Worst, 10 is Best
How would you describe your relationship with your peers?
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Please briefly describe any history of abuse, neglect, and/or trauma
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Please briefly describe your self-care and coping skills
*
What are your diet, weight, and exercise/activity patterns
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Is spirituality important in your life and if so, please explain
*
Education & Career
Highest Education Completed
High School/GED
College Degree
Graduate Degree
Vocational Degree
Employment Satisfaction
Worst
1
2
3
4
5
6
7
8
9
Best
10
1 is Worst, 10 is Best
What is your current employment
*
Any past career positions that you feel are relevant
What do you think are your strengths?
Please check all that apply to you
Depression
Now
Past
Mood Changes
Now
Past
Anger or Temper
Now
Past
Panic
Now
Past
Fears
Now
Past
Irritability
Now
Past
Concentration
Now
Past
Headaches
Now
Past
Loss of Memory
Now
Past
Excessive Worry
Now
Past
Wetting the Bed
Now
Past
Trusting Others
Now
Past
Communication with Others
Now
Past
Separation Anxiety
Now
Past
Alcohol/Drugs
Now
Past
Drinks Caffeine
Now
Past
Frequent Vomiting
Now
Past
Eating Problems
Now
Past
Severe Weight Loss
Now
Past
Severe Weight Gain
Now
Past
Head Injury
Now
Past
Parents Divorced
Now
Past
Seizures
Now
Past
Cries Easily
Now
Past
Problems with Friends
Now
Past
Problems in School
Now
Past
Fear of Strangers
Now
Past
Fighting with Siblings
Now
Past
Issues Re-Divorce
Now
Past
Sexually Acting Out
Now
Past
History of Child Abuse
Now
Past
History of Sexual Abuse
Now
Past
Domestic Violence
Now
Past
Thoughts of Hurting Someone Else
Now
Past
Hurting Self
Now
Past
Thoughts of Suicide
Now
Past
Sleeping Too Much
Now
Past
Sleeping Too Little
Now
Past
Waking Too Early
Now
Past
Nightmares
Now
Past
Sleeping Alone
Now
Past
Stomach Aches
Now
Past
Fainting
Now
Past
Dizziness
Now
Past
Diarrhea
Now
Past
Shortness of Breath
Now
Past
Chest Pain
Now
Past
Lump in Throat
Now
Past
Sweating
Now
Past
Heart Problems
Now
Past
Muscle Tension
Now
Past
Bruises Easily
Now
Past
Allergies
Now
Past
Often Makes Careless Mistakes
Now
Past
Fidgets Frequently
Now
Past
Impulsive
Now
Past
Waiting His/Her Turn
Now
Past
Completing Tasks
Now
Past
Paying Attention
Now
Past
Easily Distracted by Noises
Now
Past
Hyperactivity
Now
Past
Chills or Hot Flashes
Now
Past
Family History including yourself (check all that apply)
Impulsive
Drug/Alcohol Abuse
Legal Trouble
Domestic Violence
Suicide
Physical Abuse
Sexual Abuse
Hyperactivity
Learning Disabilities
Depression
Anxiety
Psychiatric Hospitalization
Nervous Breakdown
Any Other Information You Would Like to Include?
Client Signature
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