Client Admission Form

Jeffrey Nelson, LCSW, PLLC
1805 S. Bellaire St., Ste 219
Denver, CO 80222

Client Admission Form
Client Name*
Email*
example@example.com
Sex*
Date of Birth*

MonthDayYear
Date
Insurance*
Date of Evaluation*

MonthDayYear
Date
Reason for seeking counseling including background information*
Check the current symptoms:
Check the current symptoms:*

Suicidal IdeationHomicidal IdeationAppetite ProblemsSleep DisturbanceAnger/IrritabilityDomestic ViolenceFamily ConflictIntense Family DistancingCommunication/Trust ProblemsChronic Medical ProblemsBinging/PurgingIsolation/WithdrawalAggression/ViolencePoor Impulse ControlDestructive BehaviorVictim of AbusePerpetrator of AbuseAddictive BehaviorAlcohol/Substance AbuseGrief/LossParenting IssuesSexual/Intimacy IssuesDepressionAnxiety/PanicPhobia/FearObsessions/CompulsionsBizarre BehaviorProblems Thinking/ConcentratingMood SwingsStress/Feeling OverwhelmedLegal/Financial ProblemsReligious/Spiritual IssuesTearful/Crying Spells
Previous Treatment:*

YesNo
If yes, please indicate dates, whether inpatient/outpatient, problem for which you were treated, and name of treating professional:*
Please list any allergies/drug sensitivities:
Indicate current medications, dosage:
Name and phone. number of prescribing professional:
If not on medication, is a referral for a medication evaluation needed?

YesNo
Name & phone of Primary Care Physician:
Permission to contact Primary Care Physician regarding treatment:

YesNo
If Client is under 18, check current symptoms below in addition to those above:

TantrumsInattentionLying/Manipulative BehaviorFire SettingRunning AwaySeparation AnxietyBed WettingHyperactiveAggressionRisk Taking BehaviorSchool ProblemsDivorce/SeparationNight TerrorsOppositional BehaviorDestruction of PropertyStealingUnusual birth/pregnancy eventsBlended Family Issues
Please list past & present tobacco, alcohol, and drug use:
List Strengths/Accomplishments:
Client Signature*

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Date*

MonthDayYear
Date
Client Signature

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Date

MonthDayYear
Date
Should be Empty: