Client Questionnaire

(408) 800-5736 mft@counselingrecovery.com www.CounselingRecovery.com

Name

Date

Address

Preferred number

Cell

Email

example@example.com

Referred by

Age

Marital status

Divorces

Occupation

Gender and ages of children

Emergency contact information

Explanation of how client may be contacted by therapist

How did you find me If online specify which website

Are you interested in being on an emailing list for my blogs or workshops in my practice

example@example.com

Do you need a super bill for you to submit to your insurance

Reasons for seeking therapy

Do you have any specific goals for therapy

Medical History Have you ever been diagnosed with a serious illness?

Have you ever been diagnosed with a serious illness

When was your last physical exam

Please describe your overall health today

Substance Use History Have you ever been in a 12-step program? Please describe

Do you smoke marijuana

What age did you start

How long have you used it

Do you currently use illegal drugs

Do you drink alcohol

How old were you when you had your first drink

On average, how much alcohol do you consume in a week?

Have you ever had a DUI

Have you ever blacked out when drinking

Has anyone in your life ever expressed concern about your drinking

Have you ever used illegal drugs

Do you have any other addictions

Do any members of your family including extended family have addictions If so what

Describe your relationship

Please describe your interests/hobbies:

Have you ever been in therapy before When and how long

What was the focus of treatment?

Name of treating therapist(s), telephone number(s)

Have you ever been hospitalized for mental or emotional problems

Are you currently taking any prescription medications

How long

Have you ever attempted suicide

When

Describe the circumstances that led to that attempt

Are you currently having any suicidal thoughts

Does anyone in your family have a history of suicide attempts

How would you describe your childhood?

What was your most difficult moment in childhood

Did you ever experience, verbal, physical, emotional, sexual abuse? Please describe

Have you ever been a victim of a violent crime or traumatic experiences Please describe

How do you handle anger

Do you have close friendships with others

Is there any important information you think I should know about you?

Thank you for taking the time to fill this out. Please bring this form along with the Informed Consent as well as the name and number to whom the written report will be sent.