New Client Information Form

NEW CLIENT INFORMATION

*NOTE: If you are a parent/guardian completing this form on behalf of a minor or person under guardianship, please provide information pertaining to the identified client.
Date

MonthDayYear
Date
Name: First and Last:
Preferred Name / Nickname:
Date of Birth:

MonthDayYear
Sex:
Pronouns:
Address

Mailing Address

Street Address Line 2

CityState / Province

Postal / Zip Code
State:
Zip Code:
Work Phone:
Work Phone:
Cell Phone:
Email:
example@example.com
Preferred Contact Method:
Occupation:
Employer:
Financial Information
Client Social Security Number:
Person financially responsible:
(if same as client, skip to Emergency Contact Information)
Relationship to Client:
Address:

Mailing Address

Street Address Line 2

CityState / Province

Postal / Zip Code
State:
Zip Code:
Phone:
Email
example@example.com
Insurance Carrier / Plan
Grp:
Policy Number:
Phone
Copay if applicable
Would you like us to provide you with super bills for insurance reimbursement?
EMERGENCY CONTACT INFORMATION
Name: First and Last:
Relationship:
Home Phone:
Cell Phone:
Please check which services you are interested in receiving:

Individual TherapyGroup therapyCouples/Family TherapyTrauma-Sensitive YogaNutrition CounselingADHD Medication Management
MEDICAL, MENTAL HEALTH & WELLNESS INFORMATION
Names and Dates of Previous Therapists/Mental Health Treatment Providers:
Name:
Dates Seen:

MonthDayYear
Date
Name:
Dates Seen:

MonthDayYear
Date
Have you ever been given a mental health diagnosis?
Do you currently take psychiatric medication?
Have you ever taken psychiatric medication?
Please list the name(s), dosage(s), frequency and dates of current/ past medication(s):
Have you found medication helpful?
Medication allergies / side effects:
Prescribing Physician(s):
Have you ever been hospitalized for a psychiatric reason?
Hospital Name(s), Dates and Reason(s):
General Practitioner / Physician Name, Phone and Location:
Date of Last Physical Exam:

MonthDayYear
Outcome:
Please briefly describe any health issues / symptoms that have had a significant impact on you. (include allergies, hospitalizations, surgeries, medical conditions, etc.):
Do you... Consume caffeine?
If so, how much?
Consume alcohol?
If so, how much?
Do you smoke?
If so, how much?
Do you use recreational drugs?
If so, how much?
Take any vitamins / supplements?
If so, what do you take?
Please describe your eating habits:
Please describe your exercise habits / overall activity level:
How is your sleeping?
Family Information and History:
Who is in your immediate family and/or support system (please list name(s), age(s) and relationship(s) to you)?
Marital Status: (Check one):

SingleMarriedSeperatedDivorcedWidowedDomestic PartnerOther
Spouse / Partner Name:
Please describe any significant mental health history in your family:
Are any of your family members currently receiving services at Trivium New England Integrative Mental Health?
Please briefly describe the reasons for which you are seeking services:
Are there symptoms / stressors that are particularly concerning to you at this time?
How did you learn about Trivium New England Integrative Mental Health?*
Would you like to join our electronic mailing list?*

YesNo
Client Symptom Questionnaire

Over the last 2 weeks, how often have you been bothered by the following problems?

	Not at all	Several days	More than half the days	Nearly every day
1. Little interest or pleasure in doing things
2. Feeling down, depressed or hopeless
3.Trouble falling asleep or staying asleep, sleeping too much
4. Feeling tired or having little energy
5. Poor appetite or overeating
6. Feeling bad about yourselfor that you are a failure or have let yourself or family down
7. Trouble concentrating on things, such reading the newspaper or watching TV
8. Moving or speaking so slowly that other people could have noticed. Or the opposite-being so fidgety or restless that you have been moving around a lot more
9. Thoughts that you would be better off dead, or hurting yourself

Over the last 2 weeks, how often have you been bothered by the following problems?

	Not at all	Several days	More than half the days	Nearly every day
1. Feeling nervous, anxious, or on edge
2. Not being able to stop or control worrying
3. Worrying too much about different things
4. Trouble relaxing
5. Being so restless that it is hard to sit still
6. Becoming easily annoyed or irritable
7. Feeling afraid as if something awful will happen

1) Have you wished you were dead or wished you could go to sleep and not wake up?
2) Have you had any actual thoughts of killing yourself?
If yes to answer 2, answer questions 3,4,5, and 6. If no to 2, go directly to question 6
3) Have you been thinking about how you might do this?
(e.g., “I thought aboutTaking an overdose but INever made a specific planAs to when, where or howI would actually do it...And I would never go through with it”)
4) Have you had these thoughts and had some intention of acting on them?
As opposed to “I havethoughts but I definitelywill not do anything about them”
5) Have you started to work out or worked out the details of how you would kill yourself?
6) Do you intend to carry out this plan?
(if yes to question 5)
7) Have you ever done anything, started to do anything, or prepared to do anything to end your life?
Examples: Collected pills, obtained a gun, gave away valuables, wrote a will or suicide note, took out pills but didn’t swallow any, held a gun but changed your mind or it was grabbed from your hand, went to the roof but didn’t jump; or actually took pills, tried to shoot yourself, cut yourself, tried to hang yourself, etc.
If yes to question 7, was this within the last 3 months?
Thank you for answering our questions – this information helps us begin to understand your needs and how we can help. If we need further information, or if you have additional questions, we are happy to offer a free 15-minute consultation before scheduling your first appointment. We look forward to speaking with you!
Should be Empty:

NEW CLIENT INFORMATION

Financial Information

EMERGENCY CONTACT INFORMATION

MEDICAL, MENTAL HEALTH & WELLNESS INFORMATION

Family Information and History:

Client Symptom Questionnaire