Today’s Date (MM/DD/YYYY)
Identification
Name of Person Completing this Form
Client's Full Name (if different from above)
Date of Birth (MM/DD/YYYY)
Age
Nicknames or Aliases
Drivers License #
Home Street Address
Apt Number #
City
State
Zip Code
Cell Phone Number
May I leave a voicemail at this number? Yes No
Other Phone Number
Email Address
May I contact you at this address? Yes No
May I send automatic appointment reminders to this email address? Yes No
How did you find out about my practice? If you were referred by another provider, please give their name:
Is there anyone you would like me to speak with or receive records from? If so, please list them here, and I will ask you to complete a Release of Information form when we meet.
Ethnicity/National Origin
Race (or other similar way you identify yourself and consider important)
Gender Identity
Sexual Orientation
Current Religious Denomination/Affiliation None Protestant Catholic Jewish Muslim Buddhist Hindu Other
If other, please specify
Current Involvement None Some/Irregular Active
How important are spiritual concerns in your life?
Marital Status
Occupation/Student Status
Employer/School
Insurance Please complete this section if you wish to use in-network insurance benefits.
Insurance Plan Name
Insurance ID/Policy #
Insurance Policy Group #
Insurance Card Contact Phone #
Insurance Card Contact Address
Name of Primary Insured Person (if different from client/self)
Address of Primary Insured Person (if different from client/self)
Primary Insured Person’s Phone # (if different from client/self)
Primary Insured Person’s Date of Birth (if different from client/self)
Primary Insured Person’s Employer (if different from client/self)
Emergency Information In case of an emergency, whom should I contact? *At least one contact is required.
Contact #1
Name
Phone
Relationship to you
Address
Contact #2
Current Concerns
Please briefly describe the reason for your visit and your goals for therapy:
Symptom Checklist Please mark all of the items below that apply. You are welcome to list other concerns, or expand on these responses, in the boxes below. I have no problems or concerns at this time Abuse - physical, sexual or emotional Academic concerns Aggression/violence Alcohol use Anger, hostility, arguing, irritability Anxiety/nervousness Attention, concentration, distractibility Career concerns Childhood issues (your own childhood) Codependence Confusion Custody concerns Decision making, indecision, mixed feelings, putting off decisions Delusions (false ideas) Dependence Depression (low mood, sadness, crying) Divorce/separation Drug use (prescription medicines, over-the-counter medicines, street drugs) Eating problems - overeating, undereating, appetite, vomiting Emptiness Fatigue, tiredness, low energy Fears/phobias Fertility concerns Financial or money troubles, debt, impulsive spending, low income Gambling Grieving/loss Guilt Inferiority feelings Interpersonal conflicts Impulsiveness, loss of control, outbursts Irresponsibility Judgement problems, risk taking Loneliness Marital conflict, distance/coldness, infidelity/affairs, remarriage, disappointments, different expectations Medical concerns Memory problems Menopause Menstrual problems/PMS Mood swings Motivation/laziness Obsessions/compulsions (thoughts or actions that repeat themselves) Oversensitivity to rejections Pain Panic or anxiety attacks Parenting Perfectionism Poor self-care Postpartum concerns Pregnancy concerns Procrastination Relationship problems (with friends, relatives, colleagues) Self-esteem Sexual issues Sexual assault/rape Sexual orientation/identity Shyness Sleep problems Smoking or tobacco use Spiritual, religious, moral, ethical issues Stress Suspiciousness, distrust Temper problems Thought disorganization and confusion Weight and diet issues Withdrawal/isolation Work problems Other
If you checked Other, please explain your response here:
If you would like to expand on your response(s) to any other symptom(s) checked, please do so here:
Treatment
Have you previously received mental health or counseling services (including outpatient therapy, medication management/psychiatry, drug/alcohol treatment, inpatient hospitalization)? Yes No
If yes, please list when treatment occurred, who provided it, what the treatment was for, and the outcome of the treatment:
If yes, please list the name of the medication(s), when they were taken, who provided them, and what the outcome was:
Please list any current or past medical conditions:
Please list any current medications or supplements:
Relationships in your family of origin Please briefly describe the following:
Your parents’ relationship with each other:
Your relationship with each parent (or other caregiver):
Your relationship with your brothers and sisters, in the past and present:
Please list any medical problems, drug and alcohol use, and mental or emotional difficulties in your family:
Current Relationships Please briefly describe the following:
Your relationship with your past or current partner/spouse (if applicable):
Your relationship with your children (if applicable):
Your past and current friendships (or other important relationships):
Chemical Use
How many caffeinated drinks (coffee, tea, soda, energy drinks) do you consume each day?
Do you use tobacco? Yes No
If yes, how much tobacco do you use per day?
On average, how much beer, wine and hard liquor do you consume each week? Please indicate amounts for each type
Are there times when you drink to unconsciousness, or experience loss of memory after drinking? Yes No
Do you currently use any drugs (not including medications prescribed for you by a medical professional)? Yes No
Have you used drugs in the past (not including medications prescribed for you by a medical professional)? Yes No
If you answered yes to either current or past drug use above, please provide details of this use, including type, their effects, the amounts used, your frequency of use, and any treatments or attempts to stop use:
Legal History
Are presently suing anyone, or thinking of suing anyone? Yes No If yes, please explain:
Is your reason for coming to see me related to an accident or injury? Yes No If yes, please explain:
Are you required by a court, the police, or a probation/parole officer to have this appointment? Yes No If yes, please explain:
Are there any other legal issues I should know about? Yes No If yes, please explain:
Other Information Is there anything else that is important for me to know about that hasn’t been covered elsewhere in this form? If so, please describe it below: