Client History Form
1. Personal Information
Client Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender Identity
Please Select
Male
Female
Nonbinary
Prefer to self-describe
Decline to state
Preferred Pronouns
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Phone Number
*
Format: (000) 000-0000.
Email
*
example@example.com
Occupation/Employer
Relationship Status
*
Please Select
Single
Married
Partnered
Divorced
Widowed
Emergency Contact Name
*
First Name
Last Name
Relationship to Emergency Contact
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Client Confirmation
*
I confirm that the information above is accurate.
Client Initials
*
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2. What Brings You In
What is the primary reason you are seeking therapy or KAP at this time?
*
Please describe in 3–5 sentences.
What specific goals do you hope to achieve through Ketamine-Assisted Psychotherapy (KAP)?
*
Please describe in 3–5 sentences.
Have you ever experienced KAP or other psychedelic therapies before?
*
Yes
No
If you have experienced KAP or other psychadelictherapies before, please tell us about your experience.
Please describe in 3–5 sentences.
Client Confirmation
*
I confirm that the information provided about my reasons for seeking therapy and goals is accurate.
Client Initials
*
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3. Presenting Concerns
What symptoms or concerns are you experiencing?(Check all that apply)
*
Anxiety
Depression
Stresss
Panic attacks
Trauma/flashbacks
Difficulty sleeping
Anger management
Relationship issues
Addiction/substance use
Chronic pain
Suicidal thoughts
Other
If Other, please describe.
Client Confirmation
*
I confirm that the presenting concerns I listed are accurate.
Client Initials
*
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4. Relationships & Children
Do you have children?
*
Yes
No
If yes, please list children's ages.
Please describe your current relationships (e.g., spouse, partner, friends, family):
*
Please describe in 3–5 sentences.
Do you feel supported by your relationships?
*
Yes
No
If there are current challenges, please describe them here.
Please describe in 3–5 sentences.
Client Confirmation
*
I confirm that the information provided about my relationships is accurate.
Client Initials
*
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5. Spiritual & Religious Beliefs
Do you identify with a particular religion or spiritual belief system?
*
Yes
No
Please specify your religion or spiritual belief system.
How important is spirituality or religion in your life?
*
Please Select
Very important
Somewhat important
Not important
Do you engage in any spiritual practices (e.g., meditation, prayer, rituals)?
*
Yes
No
Please describe any current spiritual practices.
Client Confirmation
*
I confirm that the information provided about my spiritual or religious beliefs is accurate.
Client Initials
*
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6. Mental Health History
Have you ever received a mental health diagnosis?
*
Yes
No
If you have received a previous diagnosis or diagnoses, please specify.
Have you participated in therapy or counseling before?
*
Yes
No
Please share more about your previous therapy or counseling experience(s).
Have you been hospitalized for mental health concerns?
*
Yes
No
If you have been hospitalized previously, please share dates and reasons for hospitalization.
Client Confirmation
*
I confirm that the mental health history provided is accurate.
Client Initials
*
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7. Substance Use History
Do you currently use any substances (alcohol, cannabis, recreational drugs)?
*
Yes
No
If yes, please describe frequency and type.
Do you have a history of substance abuse or dependency?
*
Yes
No
If you have a history of substance abuse or dependency, please describe further.
Client Confirmation
*
I confirm that the substance use history provided is accurate.
Client Initials
*
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8. Medical History
Do you have any current medical conditions?
*
Yes
No
If you do have current medical conditions, please describe here.
Do you have a history of the following? (Check all that apply)
*
High blood pressure
Heart disease
Thyroid issues
Diabetes
Seizures
Chronic pain or illness
Allergies
Other
None of the above
List allergies.
Please describe the history of other conditions.
List all current prescription medications and how often you take them.
Client Confirmation
*
I confirm that the medical history provided is accurate.
Client Initials
*
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9. Family History
Is there a family history of mental health conditions?
*
Yes
No
If yes, please describe.
Is there a family history of substance abuse?
*
Yes
No
If yes, please describe.
Client Confirmation
*
I confirm that the family history provided is accurate.
Client Initials
*
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10. Trauma History
Have you experienced any of the following?
*
Emotional abuse
Physical abuse
Sexual abuse
Neglect
Loss or bereavement
Accidents or natural disasters
Other trauma
None of the above
Please describe.
Are there specific traumatic events you would like to address in therapy?
*
Yes
No
Please describe.
Client Confirmation
*
I confirm that the trauma history provided is accurate.
Client Initials
*
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11. Lifestyle & Strengths
What activities bring you joy or help you cope with stress?
*
Do you engage in regular physical activity or exercise?
*
Yes
No
Please describe your exercise routine.
Client Confirmation
*
I confirm that the lifestyle information provided is accurate.
Client Initials
*
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12. Anything Else Relevant to Your Care
Is there anything else you’d like to share that is relevant to your care, treatment goals, or therapy experience?
Client Confirmation
*
I confirm that the information I have provided in this section is accurate and complete.
Client Initials
*
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Acknowledgment
Client Confirmation
*
I have completed this Client History Form to the best of my ability. I understand that providing accurate information is critical to my care.
Signature
Date
-
Month
-
Day
Year
Date
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