Adult Information Form
Complete your personal, demographic, and history details to help SpringHaven Counseling Center understand your needs.
Full Name
*
Full Name
Date of Birth
*
-
Month
-
Day
Year
Back
Next
Save
Demographic Information
Marital status
Married
Divorced
Separated
Widowed
Single
If applicable, how long have you been married/divorced/separated/widowed?
Partner's name
Partner's occupation
Children
Children
Rows
Name
Age
Male/
Female
Living at
home
(yes/no)
Married
(yes/no)
School grade/
Occupation
Child 1
Child 2
Child 3
Child 4
Child 5
Child 6
Child 7
Child 8
How is your relationship with your partner?
Good
So-So
Conflict/Tension
Explain
How is your relationship with your children?
Good
So-So
Conflict/Tension
Explain
Back
Next
Save
Family History
Were there any difficulties with your birth?
No
Yes
Don't know
Explain
How was your health as a child?
Good
So-So
Bad
Don't know
How many brothers do you have?
How many sisters do you have?
Where were you in the birth order of your siblings?
Were you or a sibling abused (emotionally, physically, sexually) as a child?
No
Yes
Don't know
Explain
Was your childhood overall:
Good
So-So
Bad
Can't remember much
Significant life events from your childhood (deaths, abuse, divorce, illness, moves, adoption, etc.)
How was your relationship with your dad?
Good
So-So
Bad
Other
Other
Describe
How was your relationship with your mom?
Good
So-So
Bad
Other
Other
Describe
How was your relationship with your siblings?
Good
So-So
Bad
Other
Other
Describe
Did your parents or siblings have mental health problems or addictions?
No
Yes
Describe
Back
Next
Save
School History
What is the highest grade that you have completed?
How would you describe your learning ability?
I did very well in school
Average
School was hard for me
I had a learning disability
Describe
How was your relationship with your classmates?
Good
Teased/Bullied
So-So
Other
Other
Describe
Back
Next
Save
Work History
Are you working now?
No
Yes
Where?
How long have you been at this job?
How do you feel about your job?
Enjoy it
Tolerate it
Dislike it
How do you get along with your boss/supervisor?
Good
So-So
Bad
How do you get along with co-workers?
Good
So-So
Bad
Have you ever been fired from a job?
No
Yes
Describe
Previous jobs heldPrevious jobs heldConfigurable list
Are finances a big stress for you or your family?
No
Yes
Back
Next
Save
Social History
Do you have any close friends?
No
Yes
Do you have anyone to talk to about your concerns?
No
Yes
Who?
Is your current social activity:
Too little
About right
Too much
What do you like to do for fun?
Back
Next
Save
Spiritual/Religious Involvement
Is your spirituality/faith/church important to you?
No
Yes
Name of religion and ministers/leaders
How is your relationship with your church/ministry/leadership?
Not applicable
Positive/encouraging
Not sure they understand me/my family
I feel comfortable talking with them about my questions/concerns
I want to explain more
Explain
Would you like spiritual/religious values included in your counseling?
No
Yes
Not sure
Back
Next
Save
Medical History
Primary Care Physician
Physician Address
Physician Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Last medical exam
How would you rate your physical health?
Excellent
Good
Fair
Poor
Very poor
List any medical problems you are experiencing
List all current medications and the reason for taking each
Are you allergic to any medications?
No
Yes
What?
Please list any surgeries with dates
Have you experienced any of the following illnesses?
amputations
anemia
arteriosclerosis
arthritis
asthma
cancer
cardiac disease
cerebral palsy
ulcers
diabetes
fibromyalgia
gastrointestinal disease
hemophilia
hepatitis
high blood pressure
HIV
kidney disease
liver disease
loss of hearing
multiple sclerosis
loss of sight
thyroid problems
muscular dystrophy
Parkinson's disease
polio
neurological disability
respiratory disease
seizures/convulsions
STD's
tuberculosis
chronic osteomyelitis
osteoporosis
other
Other, describe
Back
Next
Save
Drug and Alcohol History
Do you have a history of abuse or dependence on:
Tobacco
No
Yes
Date of last use
Alcohol
No
Yes
Date of last use
Prescription drugs
No
Yes
Date of last use
Over the counter drugs
No
Yes
Date of last use
Illegal drugs
Age of first use
Alcohol/Drug treatment?
No
Yes
Describe
Involvement with AA/NA?
Never
Past
Current
Back
Next
Save
Legal History
Any felonies?
No
Yes
Describe title of charges, dates, and consequences
Any misdemeanors?
No
Yes
Describe title of charges, dates, and consequences
Back
Next
Save
Mental Health History
Have you ever been to counseling before?
No
Yes
Where, when
Do you have any problems with addiction?
No
Yes
Describe
Have you ever been diagnosed with a mental health disorder?
No
Yes
Describe
Have you ever been hospitalized due to a mental health disorder?
No
Yes
When, where, what happened
Have you ever taken medication for a mental health disorder?
No
Yes
What, when, why did you stop
Do you have any suicidal thoughts?
No
Yes
Have you ever attempted suicide?
No
Yes
Do you have any history of violence?
No
Yes
Describe
Do you have any concerns about health/weight/body image?
No
Yes
Please describe why you are here
*
What would you like to accomplish from counseling?
How motivated are you to engage in counseling?
Not at all
1
2
3
4
5
6
7
8
9
Very motivated
10
1 is Not at all, 10 is Very motivated
Back
Next
Save
Sign and Submit
Client Signature
*
Date
*
-
Month
-
Day
Year
Date
Save
Submit
Should be Empty: