BJC Client Self-Report Form

Client Self Report Form
Please complete this entire form. It provides essential details to be used in providing and evaluating the quality of client care provided to you by this office. It is appreciated that you do not leave any blanks. Please be honest we are here to help you, not judge you.
Today's Date

MonthDayYear
Date
Client Information:
Name
DOB
Age
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Cell Phone
**Is it ok to leave messages on your answering machine or voice mail?

YesNo
Email address
example@example.com
Emergency Contact(s):
Name
Relationship
Phone Number(s)
Please enter a valid phone number.
Name
Relationship
Phone Number(s)
How did you hear about us?
Personal and Family
Last year of school completed:

9101112GEDCollege
If college, which year?

1234
Marital Status:

SingleEngagedNever MarriedWidowedSeparatedDivorcedLiving together without marriage
If married,spouse name:
How long married?
Are you happy in this marriage?

YesNoSometimes
Any prior marriages for you? Yes or No if yes how many?
Any prior marriages for spouse? Yes or No if yes how many?
Do you have children?
If so, how many?
Ages:
Do they live with you?
What are your child(ren) names:
Counseling History
Have you ever had counseling for any reason?

YesNo
If yes, what was the reason?
If yes, how long?
If yes, who was your counselor?
Are you presently working with any other Counselor or Psychologist?

YesNo
Are you currently involved in a support group?

YesNo
Briefly state the nature of the problem as you see it:
What do you want to gain from counseling?
Spiritual History
Do you believe in God?

YesNoNot Sure
Are you saved?

YesNoNot Sure
What is your religious affiliation
How often do you attend church?

AlwaysOftenSeldomNever
How is your spiritual life?
Medical Information
Family Physician:
Psychiatrist:
Are you taking any prescription drugs?

YesNo
If yes, please state the reason why?
Please list ALL drugs:
Who prescribed them?
How often do you see this doctor?
Have you ever been hospitalized for mental illness or substance abuse?

YesNo
How long were you in treatment?
How long ago?
Impact of Life Circumstances
Click any Losses that you have experienced:

SpouseChildFatherMotherSisterBrotherGrandmotherGrandfatherFriendDivorceSeparationBroken EngagementSuicide AttemptMiscarriageAbortionInfertilityBankruptcyHomelessnessEmploymentSerious IllnessForeclosureOther
Click any Victimizations you have experienced or been involved with:

AbandonmentRapeRobberyAssaultSuicide AttemptAuto AccidentSurgeryPhysical DisabilityAlienationOther
Child Abuse:

PhysicalEmotionalSexualIncestOther
Spouse Abuse:

PhysicalEmotionalSexualOther
Click any problems that concern you now:

Relationship with spouseRelationship with childrenRelationship with parentsRelationship with In-lawsRelationship with co-workersRelationship with friendsAlcoholIllegal DrugsPrescription DrugsBinge EatingExcessive DietingExcessive ShoppingGamblingWork too muchProcrastinationCommunication IssuesDepressionAngerStressAnxietyGriefGender IdentitySexCareerLonlinessMood SwingsSelf EsteemCo-dependencyFearFeelings about church or GodFeel lost (need direction)Other
Intense Emotional Distress
Are you currently......
Having suicidal thoughts, plans, attempts?

YesNo
Having homicidal thoughts, plans, attempts?

YesNo
Desire to cause pain to self or others?

YesNo
In fear for your life or personal safety?

YesNo
Too depressed to care for yourself or family?

YesNo
Are you committed to your counseling journey?

YesNo
In signing below, I affirm that the information given on this form is true and complete.
Client Name printed
Date

MonthDayYear
Date
Client Signature

Clear
Should be Empty:

Client Self Report Form