Language
  • English (US)
  • Español
  • New Client History Form

    New Client History Form

  • This form helps us better understand your background, concerns, and goals for treatment. The information you share allows your clinician to prepare for your care and provide services that are appropriate and individualized.

  • Your Information

  • Please note: Unless otherwise stated, all questions are intended to be answered about the client. If you are completing this form on behalf of someone else, please answer from their perspective.

  • Date of birth*
     / /
  • Is your legal gender the same as your current gender identity?*
  • Format: (000) 000-0000.
  • Preferred method of contact (select all that apply):*

  • By listing emergency contacts, you authorize us to contact the designated person(s) in the event of an emergency.

  • Insurance Information

  • Do you plan to use health insurance for your sessions?
  • Are you the subscriber?*
  • Subscriber Date of Birth*
     - -
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof

  • We do our best to accurately quote your insurance benefits. A quote is not a guarentee of how claims will process, and we highly recommend that you contact your insurance company to verify benefits.

  • Do you have secondary insurance?*
  • Are you the subscriber?*
  • Subscriber Date of Birth*
     - -
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof

  • After processing through both insurances, you are responsible for any costs that your secondary insurance does not cover. 

    Many secondary insurance policies will not cover cost share until the primary insurance deductible is met. Please contact your secondary insurance company to verify.

  • The Support You’re Looking For

  • Your Health History

  • Have you participated in therapy or other forms of mental health treatment in the past?*
  • Have you ever completed any psychological or neuropsychological testing (like for learning, attention, or emotional concerns)?*
  • Would you like us to request records from any previous therapists or mental health providers?

  • If you would like your therapist / Silver Linings Counseling to obtain previous medical records from another therapist, please fill out a Release of Information form.

  • Have you ever been admitted to a hospital for health-related concerns, either physical or mental?*
  • Have you experienced any events that felt traumatic or overwhelming?*
  • Have you ever faced abuse—emotional, physical, or sexual?*
  • Do any family members have a history of mental health conditions?*
  • Are you currently on any medications for physical or mental health?*

  • Your Substance Use History

  • Have you ever received treatment for substance use or addiction?*
  • Are you aware of any substance use concerns in your family?*

  • Developmental History

  • Were you born full-term?*
  • Were there any medical or birth-related complications when you were born?
  • Did you experience any delays in reaching typical developmental milestones?*

  • Family & Social Background

  • Were you adopted or raised by someone other than your biological parents?*
  • Do you observe any religious, spiritual, or cultural practices we should be aware of?*
  • Do you have difficulties forming friendships or getting along with people?*
  • Do you feel you have the support you need from friends, family, or others?*

  • Family & Social Background Continued

  • What is the marital status of your parents or legal guardians?
  • Is there a legal custody agreement?*
  • Format: (000) 000-0000.

  • **For divorced, separated, or non-married parents with a legal custody or financial agreement, both parents must complete the Shared Custody & Financial Consent and the Client Contract & Consent for Treatment.

    If costs are split, each parent must keep a credit card on file. Only one email can be used for the client portal; the other parent will need to call our front desk at (586) 580-2975 to provide their card and sign a Credit Card Acknowledgement. This will be indicated in the email received by the other parent.**

  • Education/Military/Work History

  • Education & Learning History

  • Do you currently have an IEP or 504 plan?*
  • Have you ever been suspended or expelled from school?*

  • Legal History

  • Are you seeking treatment due to legal or court-related reasons?*
  • Have you ever spent time in jail, prison, or another correctional facility?*
  • Are you currently involved in any pending legal matters, such as charges, trial, or sentencing?
  • Have you ever been on probation?*

  • Your Personal Story

  • Date*
     / /
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Should be Empty: