Clone of New Client Paperwork

Family & Social Background
What is your current relationship status?*
Were you adopted or raised by someone other than your biological parents?*

YesNo
Do you observe any religious, spiritual, or cultural practices we should be aware of?*

YesNo
If you’d like, please describe your practices or considerations.
Do you have difficulties forming friendships or getting along with people?*

YesNo
Do you feel you have the support you need from friends, family, or others?*

YesNo
Close Relationships & Family Members
Please share any major conflicts with family members or close people in your life.

Family & Social Background Continued
What is the marital status of your parents or legal guardians?

MarriedDivorcedSeparatedNever Married
Is there a legal custody agreement?*

YesNo
Other parent's name*

First NameLast Name
Other parent's phone number*
Please enter a valid phone number.
Other parent's email address*
example@example.com
**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
Please share your highest level of completed education.*
Have you ever served in the military or armed forces?*
Thank you for your service! Feel free to share information about your service, such as branch, rank, and years served.
Are you working at this time?*
Please share details about your current employment, including role, employer, and schedule.

Education & Learning History
Current grade:*
Do you currently have an IEP or 504 plan?*

YesNo
Have you ever been suspended or expelled from school?*

YesNo
Please share any school-related attendance or behavioral difficulties, including disciplinary actions if applicable.:*
Please indicate any after-school programs or activities you take part in.*

Your Personal Story
What do you consider to be your strengths? List as many as you can!*
Tell us about any supports or accommodations that would be helpful for you.*
Examples: Stress reduction, improved relationships, impulse control, relaxation skills, etc.
Do you have any preferred approaches to care?*
Therapist style (e.g., humor, personal examples), appointment frequency, specific therapy techniques, topics to avoid, etc.
Is there anything else important for us to know?
Signature*

Clear
Date*

MonthDayYear
Date
Client (or parent) ID*

Cancelof
Should be Empty:

New Client History Form