ADULT CLIENT INFORMATION FORM
Today’s data
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Month
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Day
Year
Date
Your name
First Name
Middle Initial+
Last Name
Date of birth
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Month
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Day
Year
Date
Home street address
City
State
Zip
Name of Employer
Address of Employer
City
State
Zip
Home Phone
Work Phone
Cell Phone
Email
example@example.com
Calls will be discreet, but please indicate any restrictions
Referred by
May I have your permission to thank this person for the referral?
If referred by another clinician, would you like for us to communicate with one another?
Person(s) to notify in case of any emergency name
Person(s) to notify in case of any emergency phone
I will only contact this person if I believe it is a life-or-death emergency. Please provide your signature to indicate that I may do so (typed name accepted)
Please briefly describe your presenting concerns(s)
What are your goals for therapy?
How long do you expect to be in therapy in order to accomplish these goals (or at least feel like you have the tools to accomplish them on your own)?
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Medical History
Please explain any significant medical problems, symptoms, or illnesses
Current Medications:
Name of Medication
Dosage
Purpose
Name of Prescribing Doctor
1
2
3
4
5
6
Do you smoke or use tobacco?
YES
NO
If YES, how much per day?
Do you consume caffeine?
YES
NO
If YES, how much per day?
Do you drink alcohol?
YES
NO
If YES, how much per day/week/month/year?
Do you use any non-prescription drugs?
YES
NO
If YES, what kinds and how often?
Have any of your friends or family members voiced concern about your substance use?
YES
NO
Have you ever been in trouble or in risky situations because of your substance use?
YES
NO
Previous medical hospitalizations (Approximate dates and reasons)
Previous psychiatric hospitalizations (Approximate dates and reasons)
Have you ever talked with a psychiatrist, psychologist or other mental health professional? (Please list approximate dates and reasons)
Height
Weight (if applicable)
Age
Gender
Sexual Orientation
Heterosexual
LGBTQIA+
Prefer not to say
Racial/Ethnic Identity
African/African American/Black
Latino/Latino-American
Bi-Racial/Multi-Racial
American Indian/Alaska Native
Middle Eastern/Middle Eastern-American
Asian/Asian-American/Asian Pacific Islander
White/European-American
Not listed
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FAMILY:
How would you describe your relationship with your mother?
How would you describe your relationship with your father?
Are your parents still married?
If they divorced, how old were you when they separated or divorced, and how did this impact you?
Were there any other primary care givers who you had a significant relationship with? If so, please describe how this person may have impacted your life
How many sisters do you have?
Ages?
How many brothers do you have?
Ages?
How would you describe your relationships with your siblings?
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RELATIONSHIPS & SOCIAL SUPPORT & SELF-CARE:
Currently in Relationship?
How Long?
Relationship Satisfaction: 1(poor) to 7(excellent)
Married/Life Partnered?
How Long?
Previously Married/Life Partnered?
Yes
No
If so, length of previous marriages/committed partnerships
Do you have Children?
Yes
No
If YES, How many and what are their ages:
Describe any problems any of your children are having
List the names and ages of those living in your household
Please briefly describe any history of abuse, neglect and/or trauma
Current level of satisfaction with your friends and social support: 1(poor) to 7(excellent)
Please briefly describe your coping mechanisms and self-care:
Is spirituality important in your life and if so please explain
Briefly describe your diet and exercise patterns
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Education & Career
High School/GED
College Degree
Graduate Degree (or Higher)
Vocational Degree
What is your current employment?
Employment Satisfaction: 1(poor) to 7(excellent)
Any past career positions that you feel are relevant?
What do you think are your strengths?
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Please check all of the following that you have had difficulty with
Now
Past
Anxiety
Depression
Mood Changes
Anger or Temper
Panic
Fears
Irritability
Concentration
Headaches
Loss of Memory
Excessive Worry
Feeling Manic
Trusting Others
Communicating w/ Others
Drugs
Alcohol
Caffeine
Frequent Vomiting
Eating Problems
Severe Weight Gain
Severe Weight Loss
Blackouts
People in General
Parents
Children
Marriage/Partnership
Friend(s)
Co-Worker(s)
Employer
Finances
Legal Problems
Sexual Concerns
History of Child Abuse
History of Sexual Abuse
Domestic Violence
Thoughts of Hurting Someone Else
Hurting Self
Thoughts of Suicide
Sleeping Too Much
Sleeping Too Little
Getting to Sleep
Waking Too Early
Nightmares
Head Injury
Nausea
Abdominal Distress
Fainting
Dizziness
Diarrhea
Shortness of Breath
Chest Pain
Lump in the Throat
Sweating
Heart Palpitations
Muscle Tension
Pain in joints
Allergies
Often Make Careless Mistakes
Fidget Frequently
Speak Without Thinking
Waiting Your Turn
Completing Tasks
Paying Attention
Easily Distracted by Noises
Hyperactivity
Chills or Hot Flashes
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Family History Of
Check all that apply
Drug/Alcohol Problems
Legal Trouble
Domestic Violence
Suicide
Physical Abuse
Sexual Abuse
Hyperactivity
Learning Disabilities
Depression
Anxiety
Psychiatric Hospitalization
"Nervous Breakdown"
PLEASE CHECK ALL THAT APPLY
Any additional information you would like to include
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