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Client Information Form General Information Date: Name: Date of Birth: Age: Current Address: Home Phone: Cell Phone: Best number and time to reach you directly: Can I leave a message at either or both of these numbers?_ Email: Employer: Address: _ Work Phone: How long at present job? Marital Status: Spouse s Name: Spouse s Age: Spouse s Occupation: Years Married: Previous Marriages: Yes No If yes, how many times have you been married? Children s Names Age Sex Emergency Contact: Name: Relationship: Phone #: I give my permission for this person to be contacted in case of emergency. Initial: Referral Who referred you to me? If you found my website, how did you find it? Medical Information Primary Physician: Phone: Major (or Chronic) Illnesses/Operations/Injuries: Current Medications Dosage For What? How would you characterize your overall health? Excellent Good Fair Poor 1

Mental & Emotional Health Please describe the main difficulty that has brought you to see me: Indicate the severity of your difficulties on the scale below: Mild Moderate Severe Extremely Severe Incapacitating Current signs/symptoms (Please check all that apply): Depressed Mood Anxiety More/less sleep than normal Anger/rage Poor concentration Feel overwhelmed Increase/decrease in appetite Food issues Decreased energy Body image issues Decreased motivation Feelings of hopelessness Increased/decreased sexual desire Negative view of self Compulsive behaviors (specify): Other Gambling Drugs Alcohol Spending/Shopping Sex Food Other Have you ever received psychological or psychiatric counseling before? Yes No Counselor s Name: When: Reason for counseling: Reason for ending counseling: Are you currently seeing a psychiatrist for medication management? Yes No If so, who are you seeing? Have you ever had any psychiatric hospitalizations: Yes No When?_ Primary reason for hospitalization: Please indicate the major stressors in your life in the last twelve months: Serious injury/illness Death of a close friend or relative Major illness in family Divorce/Separation Job Change Gain of a new family member Other (please describe): Have you ever thought about suicide? Yes No Have you ever attempted suicide? Yes No If yes, when? 2

Please describe what you would like to be different in your life when you are done with therapy: Family History: 1. Names and ages of your siblings: 2. Were your parents: Divorced Never Married Still Married Widowed 3. List five words to describe the following: Your Mother: Your Father: _ Your parent s relationship with each other: _ What it was like in your house growing up (i.e. chaotic, quiet, fun, etc.): _ 7. Do you have a family history of any of the following? Please note how the person is related to you. Depression Violence Suicide Attempts Sexual Abuse Anxiety Emotional Abuse Eating Disorders Alcoholism / Drug Addiction Mental Illness Sex Addiction Chronic Illness (please explain): _ Other: 3

Abuse History I was not abused in any way. I was abused. If you were abused, please indicate the following: Your age? Kind of abuse? By whom? Whom did you tell? Consequences of telling? Support Network 1. Describe your relationship with your spouse/partner: 2. Do you have friends with whom you talk about real issues of life (i.e. struggles, feelings, beliefs)? I have none I have one or two I have several 3. List any groups/organizations that you re a part of (i.e. 12 Step meetings, faith related group): Chemical Use 1. Have you ever felt the need to cut down on your drinking/substance use? No Yes 2. Have you ever felt annoyed by criticism of your drinking/substance use? No Yes 3. Have you ever felt guilty about your drinking/substance use? No Yes 4. Have you ever taken a morning "eye-opener"? No Yes 5. How much beer, wine, or hard liquor do you consume each week, on the average? 6. How much tobacco do you smoke or chew each week? 7. Which drugs (not medications prescribed for you) have you used in the last 10 years? Please provide details about your use of these drugs or other chemicals, such as amounts and how often you used them: 8. Have you ever been in a residential treatment program? No Yes If yes, when, where and for what? 4

Other Is there anything else that is important for me to know about you? Signature of Client Date Signature of Therapist Date 5

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