Client History

Client History
Date

MonthDayYear
Date
Legal Name*

First NameLast Name
Preferred Name
Race*
Date of Birth*

MonthDayYear
Date
Age
Name of Person Completing This Form
Relationship to Client
Many questions in this packet are directed towards "you". If the person completing this form is not the client, please answer all questions in regard to the client and their experiences.
Administrative Sex (what is on file with the insurance company)*

MaleFemale
Preferred Pronouns*

She / Her / HersHe / Him / HisThey / Them / TheirsOther
Billing Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Preferred Method of Contact (select all that apply):*

CallTextEmail
How did you hear about Silver Linings Counseling?*
Emergency Contact(s)*
By listing this emergency contact, you authorize Silver Linings Counseling to contact this designated person in the event of an emergency and/or when other safety concerns arise.
Insurance Information
Primary Insurance*
Member/Enrollee ID: *
Subscriber Name: *
Subscriber Date of Birth: Date*
Insurance Card Front*

Cancelof
Insurance Card Back*

Cancelof
Do you have secondary insurance?*
Secondary Insurance
Member/Enrollee ID:
Subscriber Name:
Subscriber Date of Birth: Date
Treatment Information
Please list reasons you are seeking treatment:*
When did your problems begin?*
What are your hopes for treatment?*
Medical and Psychiatric History
Please indicate if you have ever experienced:*

Extreme depressionPanic attacksHallucinationsTrouble understanding, concentrating, or rememberingTrouble controlling aggression or violent behaviorSerious thoughts of suicideSuicide attempt(s)Self-InjuryDelusionsTraumatic Brain InjurySerious thoughts of homicideIntrusive thoughtsDisordered eatingOther
Have you ever attended mental health treatment before?*

YesNo
What was your diagnosis? (if known)
Have you ever completed formal psychological testing?*

YesNo
What was your diagnosis? (if known)
Would you like us to obtain records from another therapist?

YesNo
If you would like your therapist / Silver Linings Counseling to obtain previous medical records from another therapist, please fill out a Release of Information form.
Have you ever been hospitalized or received any serious medical treatments? Please include psychiatric (inpatient/partial hospitalization programs) and non-psychiatric reasons*

YesNo
Have you ever experienced trauma or a traumatic event?*

YesNo
Please explain trauma/traumatic event:
Have you ever been the victim of emotional, sexual, or physical abuse?*

YesNo
Is there any family history of mental health issues?*

YesNoNo family history available
Family Mental Health History
Do you take any medication?*

YesNo
Substance Use History
Please indicate if you currently use or have ever used any of the following:*

CaffeineTobaccoAlcoholMarijuanaSedativesCocaineHeroinBarbituratesInhalantsHallucinogensNoneOther
If you checked any of the above, please list age of first use, current use (# of days/month) and past use (# of days/month)
Is there a family history of substance use?*

YesNoNo family history available
Family Substance Use History
Have you ever been treated for a drug-related problem?*

YesNo
If yes, please explain:
Family Background and Social History
Relationship Status
Were you adopted?*
Do you have an religious, spiritual, or cultural practices?*
If yes, please explain:
Parents are:*

MarriedDivorcedNever MarriedOther
Sexual Orientation (not required)
Have you ever struggled to make friends or get along with others?*

YesNo
Do you feel you have enough supportive people in your life currently?*

YesNo
Close Relationships / Family Members (please include family you grew up with and anyone you currently live with)*
Please explain any serious conflicts with family members*
Developmental History
Were you born full-term?*

YesNoNo history available
Were there any complications during your birth?*

YesNoNo history available
Please explain
Were there any developmental milestones that you did not meet on-time?*

YesNoNo history available
Please explain
Education/Military/Work History
Please indicate the highest level of education you have completed*
Have you ever served in the military?*
Are you employed?*
Education History
Current Grade / Level in School*
What type of classes do they have?*

RegularEmotionally ImpairedCognitively ImpairedGifted/TalentedOther
Do they have an IEP or 504b?*

YesNo
Have they ever been suspended or expelled?*

YesNo
Please describe any attendance or behavioral problems at school (including any suspensions or expulsions):*
Please list any after school activities:*
Legal History
Was this request for treatment prompted by the legal system?*
Have you ever been incarcerated?*
If yes, please explain the nature of charges
Are you presently awaiting charges, trial, or sentencing?*
Have you ever been on probation?*
Personal History
Please list as many of your strengths as possible:*
Please list any needs that you have:*
Examples: Stress reduction, improved relationships, impulse control, relaxation skills, etc.
Treatment preferences*
Therapist style (e.g., humor, personal examples), appointment frequency, specific therapy techniques, topics to avoid, etc.
Any additional information that you would like to share
Signature*

Clear
Client driver's license/ID (if under 18, please upload legal guardian's driver's license/ID*

Cancelof
Should be Empty:

Client History

Insurance Information

Treatment Information

Medical and Psychiatric History

Substance Use History

Family Background and Social History

Developmental History

Education/Military/Work History

Education History

Legal History

Personal History