CLIENT INFORMATION
Please provide the following information and answer the questions below. Please note: Information you
provide here is protected as confidential information.
Please fill out this form and bring it to your first session.
Name: _______________________________________________________________________________
(Last) (First) (Middle Initial)
Name of parent/guardian (if under 18 years):
_____________________________________________________________________________________
(Last) (First) (Middle Initial)
Birth Date: ______ /______ /______ Age: ________ Gender: □ Male □ Female
Marital Status:
□ Never Married □ Domestic Partnership □ Married
□ Separated □ Divorced □ Widowed
Please list any children/age: ______________________________________________________________
Address: _____________________________________________________________________________
(Street and Number)
_____________________________________________________________________________________
(City) (State) (Zip)
Home Phone: __________________________________
Cell/Other Phone: _______________________________
Referred by (if anyone): _________________________________________________________________
Have you previously received any type of mental health services in the past (psychotherapy, psychiatric
services, etc.)?
□ No
□ Yes, previous therapist/practitioner: _____________________________________________________
Dates______________________________________________________________________________
Are you currently taking any prescription medication?
□ Yes
□ No
Please list: ____________________________________________________________________________
_____________________________________________________________________________________
Have you ever been prescribed psychiatric medication?
□ Yes
□ No
Please list and provide dates: _____________________________________________________________
_____________________________________________________________________________________
GENERAL HEALTH AND MENTAL HEALTH INFORMATION
1. How would you rate your current physical health? (please circle)
Poor Unsatisfactory Satisfactory Good Very good
Please list any specific health problems you are currently experiencing:
_____________________________________________________________________________________
2. How would you rate your current sleeping habits? (please circle)
Poor Unsatisfactory Satisfactory Good Very good
Please list any specific sleep problems you are currently experiencing:
_____________________________________________________________________________________
3. How many times per week do you generally exercise? __________
What types of exercise to you participate in? ________________________________________________
4. Please list any difficulties you experience with your appetite or eating patterns:
_____________________________________________________________________________________
5. Are you currently experiencing overwhelming sadness, grief, or depression?
□ No
□ Yes
If yes, for approximately how long? ________________________________________________________
6. Are you currently experiencing anxiety, panic attacks, or have any phobias?
□ No
□ Yes
If yes, when did you begin experiencing this? ________________________________________________
7. Are you currently experiencing any chronic pain?
□ No
□ Yes
If yes, please describe: __________________________________________________________________
8. How often do you drink alcohol on a weekly basis (average)? _________________________________
9. How often do you engage recreational drug use? ___________________________________________
□ Daily □ Weekly □ Monthly □ Infrequently □ Never
10. Are you currently in a romantic relationship? □ No □ Yes
If yes, for how long? __________________
On a scale of 1-10, how would you rate your relationship? __________
11. What significant life changes or stressful events have you experienced recently?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
FAMILY MENTAL HEALTH HISTORY:
In the section below, identify if there is a family history of any of the following. If yes, please indicate the
family member’s relationship to you in the space provided (eg, father, grandmother, uncle, etc).
Please List Family Member
Alcohol/Substance Abuse yes/no _________________________________________
Anxiety yes/no ________________________________________________________
Depression yes/no _____________________________________________________
Domestic Violence yes/no _______________________________________________
Eating Disorders yes/no _________________________________________________
Obesity yes/no ________________________________________________________
Obsessive Compulsive Behavior yes/no _____________________________________
Schizophrenia yes/no ___________________________________________________
Suicide Attempts yes/no _________________________________________________
ADDITIONAL INFORMATION:
1. Are you currently employed? □ No □ Yes
If yes, what is your current employment situation?
_____________________________________________________________________________________
Do you enjoy your work? Is there anything stressful about your current work?
_____________________________________________________________________________________
_____________________________________________________________________________________
2. Do you consider yourself to be spiritual or religious? □ No □ Yes
If yes, describe your faith or belief:
_____________________________________________________________________________________
3. What do you consider to be some of your strengths?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
4. What do you consider to be some of your weaknesses?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
5. What would you like to accomplish out of your time in therapy?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
6. Please include any additional information that feels relevant.
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________