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
Email Address
example@example.com
Upload Picture of Identification Card

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Emergency Contact
Emergency Contact Full Name
Emergency Contact Phone Number
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?

Yes (if yes, explain below)No
3. Are you taking any Medications? If yes, list Medication name, dosage, and frequency*

Yes (if yes, List below)No
Medical Conditions
Allergies

Medications*

	Medication	Dosage	Frequency
1.
2.
3.
4.

Presenting Concerns
1. What brings you into therapy?

DepressionAnxietyStressRelationship issuesFamily concernsGrief/ LossAddictionOther
2. How long have these concerns been present?

Less than 1 month1-6 months6+ months
2. Previously had any services in the past ?

Yes (if yes, state what services)No
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?

Yes (if yes, explain)No
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?

Yes (if yes, state diagnosis below)No
2. Have you ever abused any substances?

Yes (if yes, list which substance below)No
Mental Health Diagnosis
Substance Abuse
3. Family history of mental health or substance abuse?

Yes (if yes, explain below)No
4. Have you ever experienced suicidal thoughts or attempts?

Yes (if yes, state how many and how often)No
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?

Yes (if yes, state)No
Religion
Scheduling & Availability
Preferred Days for Appointments

SundayMondayTuesdayWednesdayThursdayFridaySaturday
Preferred Times

Mornings (8 AM - 12 PM)Afternoons (12 PM - 4 PM)Evenings (4 PM - 8 PM)
Preferred Method of Contact

PhoneTextEmail
Preferred Method of Services

In PersonTelehealth (Google Meet)Consultation (15 min)
Is there anything else you'd like your therapist to know?
Client Signature

Clear
Date

MonthDayYear
Date
ParentGuardian Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Changin' You LLC

Personal Information

Emergency Contact

Insurance Information

Medical & Medication Information

Presenting Concerns

Mental Health and Substance Abuse History

Religion and Cultural Identity

Scheduling & Availability