Client Information & Psychosocial History Form

Client Name

First NameLast Name

Date of Birth

MonthDayYear

Age

Gender Identity

Pronouns

Current Living Arrangement

Who do you live with?

Relationship Status

Children (names & ages)

Support System (friends, family, community)

Religious/Spiritual Affiliation (optional)

Cultural or Identity Factors Important to Your Care

Occupation

Employer

Currently Working?

Highest Education Level

Additional Education Details

What brings you to therapy at this time?

What are your goals for therapy?

What would you like to be different in your life six months from now?

Have you received mental health treatment before?

If yes, please describe previous mental health treatment

Have you ever been hospitalized for mental health concerns?

If yes, please explain hospitalization for mental health concerns

Current symptoms (check all that apply)

Any history of self-harm or suicide attempts?

If yes, please describe history of self-harm or suicide attempts

Primary Care Provider Name & Contact

Current Medical Conditions or Diagnoses

Current Medications (including dosage & purpose)

Allergies (medication, food, etc.)

Substance Use (check all that apply)

Other Substance

Additional Information

Rows	Not at all	Several days	More than half the days	Nearly every day
Little interest or pleasure in doing things.
Feeling down, depressed, or hopeless.
Trouble falling or staying asleep, or sleeping too much.
Feeling tired or having little energy.
Poor appetite or overeating.
Feeling bad about yourself—or that you are a failure.
Trouble concentrating on things, such as reading or watching TV.
Moving or speaking so slowly that others could have noticed? Or being so restless that you are moving around a lot more than usual.
Thoughts that you would be better off dead or of hurting yourself in some way.

Rows	Not at all	Several days	More than half the days	Nearly every day
Feeling nervous, anxious or on edge.
Not being able to stop or control worrying.
Worrying too much about different things.
Trouble relaxing.
Being so restless that it is hard to sit still.
Becoming easily annoyed or irritable.
Feeling afraid as if something awful might happen.

Rows	Never	Once	More than once	Prefer not to say
Emotional Abuse: Did a parent or adult in the household often swear at you, insult you, or put you down?
Physical Abuse: Did an adult in the household often push, grab, slap, or throw something at you?
Sexual Abuse: Did an adult or person at least 5 years older than you ever touch you sexually or have you touch them?
Emotional Neglect: Did you often feel that no one in your family loved you or thought you were special?
Physical Neglect: Did you often feel you didn't have enough to eat, had to wear dirty clothes, or had no one to protect you?
Parental Separation: Were your parents ever separated or divorced?
Domestic Violence: Did you see your mother (or stepmother) being pushed, slapped, or hit?
Substance Abuse: Did you live with anyone who was a problem drinker or alcoholic, or who used street drugs?
Mental Illness: Was a household member depressed or mentally ill, or did a household member attempt suicide?
Incarceration: Did a household member go to prison?