Therapy Client Screening Form copy

Changin' You LLC
Therapy Client Screening Form

Welcome! Please fill out this form to help us understand your needs. Your information will remain confidential.
Personal Information
Full Name
Race and Gender
Date of Birth

MonthDayYear
Date
Social Security Number
Full Address
City, State, Zip-Code
Phone Number
Format: (000) 000-0000.
Email Address
example@example.com
Upload Picture of Identification Card

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Emergency Contact
Emergency Contact Full Name
Emergency Contact Phone Number
Format: (000) 000-0000.
Emergency Contact Address
Relationship
Insurance Information
Insurance Provider
Policy Number
Group Number
EAP Number
Upload Picture of Insurance Card

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Medical & Medication Information
PCP Name
Psychiatrist Name
1. Do you have any medical conditions or diagnosis?
3. Are you taking any Medications? If yes, list Medication name, dosage, and frequency
Medical Conditions
Allergies

Medications

Presenting Concerns
1. What brings you into therapy?

Other
2. How long have these concerns been present?
2. Previously had any services in the past ?
What Services?
Case Management, Substance Abuse Services, MHSB, Therapy
3. What are your goals for therapy?
4. Have you experienced any history of abuse or trauma?
What forms?
Physical, Verbal, Sexual, Mental, Emotional, or Psychological
Mental Health and Substance Abuse History
1. Have you been diagnosed with any mental health conditions in the past?
2. Have you ever abused any substances?
Mental Health Diagnosis
Substance Abuse
3. Family history of mental health or substance abuse?
4. Have you ever experienced suicidal thoughts or attempts?
Family History
Attempts
Religion and Cultural Identity
1. What particular religion, spirituality, or cultural traditions do you practice and would you like it to be considered in your therapy?
Religion
Scheduling & Availability
Preferred Days for Appointments
Preferred Times
Preferred Method of Contact
Preferred Method of Services
Is there anything else you'd like your therapist to know?
Client Signature
Date

MonthDayYear
Date
ParentGuardian Signature
Date

MonthDayYear
Date
Should be Empty:

Changin' You LLC