Client Information Form

Client Information Form

This form is completely confidential
Today's Date*

MonthDayYear
Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Social Security Number (Last four only)
Home Address*

Street Address

Street Address Line 2

CityState

Zip Code
Name of Employer
Employer Address

Street Address

Street Address Line 2

CityState

Zip Code
Home Phone*
Work Phone
Cell Phone
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.*

YesNo
Referred By:
May I have your permission to thank this person for the referral*

YesNoN/A
If referred by another clinician, would you like for us to communicate with one another?*

YesNoN/A
Person to notify in case of any emergency*
Emergency Contact Relation to Patient*
Emergency Contact Email Address*
example@example.com
Emergency contact phone number*
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*

Clear
Please briefly describe your presenting concern(s):*
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?*
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)?*
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*

Current Medications

	Name of Medication	Dosage	Purpose	Name of Prescribing Doctor
Medication One
Medication Two
Medication Three
Medication Four

Do you smoke or use tobacco?

YesNo
If Yes, how much per day?
Do you consume caffeine?

YesNo
If Yes, how much per day?
Do you use any non-prescription drugs?

YesNo
If Yes, how much per day?
Do you consume alcohol?

YesNo
If Yes, how much per day?
Has anyone voiced concern about your substance use?

YesNo
Have you ever been in trouble or in risky situations because of your substance use?

YesNo

Previous Medical Hospitalizations

	Approx Start Date	Approx End Date	Reason
Hopitalization One
Hospitalization Two
Hospitalization Three

Previous Psychiatric Hospitalizations

	Approx Start Date	Approx End Date	Reason
Psychiatric One
Psychiatric Two
Psychiatric Three

Have you ever talked with a psychiatrist or psychologist?*

YesNo
If Yes, please list approximate dates and reasons
Height*
Gender *
Age*
Weight*
Gender Identity / Preferred Pronouns
Sexual Orientation
Sexuality

HeterosexualLesbianGayBisexualTransgender
Family
How would you describe your relationship with your caretakers?*
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*

MarriedDivorcedSeparatedWidowedOther
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

	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

1

2

3

4

5

6

7

8

9

10

1 is Worst, 10 is Best
Currently Married/Life Partnered?*
How long?
Previously Married/Life Partnered?*
How long?
Do you have any children*
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*

1

2

3

4

5

6

7

8

9

10

1 is Worst, 10 is Best
How would you describe your relationship with your peers?*
Please briefly describe any history of abuse, neglect, and/or trauma*
Please briefly describe your self-care and coping skills*
What are your diet, weight, and exercise/activity patterns*
Is spirituality important in your life and if so, please explain*
Education & Career
Highest Education Completed

High School/GEDCollege DegreeGraduate DegreeVocational Degree
Employment Satisfaction

1

2

3

4

5

6

7

8

9

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

NowPast
Mood Changes

NowPast
Anger or Temper

NowPast
Panic

NowPast
Fears

NowPast
Irritability

NowPast
Concentration

NowPast
Headaches

NowPast
Loss of Memory

NowPast
Excessive Worry

NowPast
Wetting the Bed

NowPast
Trusting Others

NowPast
Communication with Others

NowPast
Separation Anxiety

NowPast
Alcohol/Drugs

NowPast
Drinks Caffeine

NowPast
Frequent Vomiting

NowPast
Eating Problems

NowPast
Severe Weight Loss

NowPast
Severe Weight Gain

NowPast
Head Injury

NowPast
Parents Divorced

NowPast
Seizures

NowPast
Cries Easily

NowPast
Problems with Friends

NowPast
Problems in School

NowPast
Fear of Strangers

NowPast
Fighting with Siblings

NowPast
Issues Re-Divorce

NowPast
Sexually Acting Out

NowPast
History of Child Abuse

NowPast
History of Sexual Abuse

NowPast
Domestic Violence

NowPast
Thoughts of Hurting Someone Else

NowPast
Hurting Self

NowPast
Thoughts of Suicide

NowPast
Sleeping Too Much

NowPast
Sleeping Too Little

NowPast
Waking Too Early

NowPast
Nightmares

NowPast
Sleeping Alone

NowPast
Stomach Aches

NowPast
Fainting

NowPast
Dizziness

NowPast
Diarrhea

NowPast
Shortness of Breath

NowPast
Chest Pain

NowPast
Lump in Throat

NowPast
Sweating

NowPast
Heart Problems

NowPast
Muscle Tension

NowPast
Bruises Easily

NowPast
Allergies

NowPast
Often Makes Careless Mistakes

NowPast
Fidgets Frequently

NowPast
Impulsive

NowPast
Waiting His/Her Turn

NowPast
Completing Tasks

NowPast
Paying Attention

NowPast
Easily Distracted by Noises

NowPast
Hyperactivity

NowPast
Chills or Hot Flashes

NowPast
Family History including yourself (check all that apply)
Impulsive

Drug/Alcohol AbuseLegal TroubleDomestic ViolenceSuicidePhysical AbuseSexual AbuseHyperactivityLearning DisabilitiesDepressionAnxietyPsychiatric HospitalizationNervous Breakdown
Any Other Information You Would Like to Include?
Client Signature*

Clear
Should be Empty:

Client Information Form

Medical History

Family

Social Support, Self-Care, and Education

Education & Career

Please check all that apply to you

Family History including yourself (check all that apply)