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
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.
Referred By:
May I have your permission to thank this person for the referral
If referred by another clinician, would you like for us to communicate with one another?
Person to notify in case of any emergency
Emergency Contact Relation to Patient
Emergency Contact Email Address
example@example.com
Emergency contact phone number
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
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

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?
If Yes, how much per day?
Do you consume caffeine?
If Yes, how much per day?
Do you use any non-prescription drugs?
If Yes, how much per day?
Do you consume alcohol?
If Yes, how much per day?
Has anyone voiced concern about your substance use?
Have you ever been in trouble or in risky situations because of your substance use?

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

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

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
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
Mood Changes
Anger or Temper
Panic
Fears
Irritability
Concentration
Headaches
Loss of Memory
Excessive Worry
Wetting the Bed
Trusting Others
Communication with Others
Separation Anxiety
Alcohol/Drugs
Drinks Caffeine
Frequent Vomiting
Eating Problems
Severe Weight Loss
Severe Weight Gain
Head Injury
Parents Divorced
Seizures
Cries Easily
Problems with Friends
Problems in School
Fear of Strangers
Fighting with Siblings
Issues Re-Divorce
Sexually Acting Out
History of Child Abuse
History of Sexual Abuse
Domestic Violence
Thoughts of Hurting Someone Else
Hurting Self
Thoughts of Suicide
Sleeping Too Much
Sleeping Too Little
Waking Too Early
Nightmares
Sleeping Alone
Stomach Aches
Fainting
Dizziness
Diarrhea
Shortness of Breath
Chest Pain
Lump in Throat
Sweating
Heart Problems
Muscle Tension
Bruises Easily
Allergies
Often Makes Careless Mistakes
Fidgets Frequently
Impulsive
Waiting His/Her Turn
Completing Tasks
Paying Attention
Easily Distracted by Noises
Hyperactivity
Chills or Hot Flashes
Family History including yourself (check all that apply)
Impulsive
Any Other Information You Would Like to Include?
Client Signature
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)