CLIENT INFORMATION FORM

Please provide the following information and answer the questions below. Information you provide here is protected as confidential information and becomes part of your medical record. Please fill out this form and bring it to your first session.

GENERAL INFORMATION

Name ________________________________________ Date of birth ______________ Age ______
Name of parent/guardian (if under 18 years) _______________________________________
Home Address _________________________________ City ________________________ State ______ Zip _________

                                                                         Ok to call?      Ok to leave a message?
Home Phone (____)___________________  Yes No           Yes  No  
Cell (____)__________________________   Yes No            Yes  No  
Work Phone (____)___________________    YesNo           Yes  No  

                                                                                       Ok to email? 
Email ______________________________________ Yes No 

Emergency Contact/Relationship ________________________________________ Phone (____)___________________ 


How did you hear about this practice? Website Insurance Friend/Family Physician Other 
Referred by ___________________________________________________

DEMOGRAPHIC INFORMATION

Gender__________ Sexual Orientation__________ Ethnicity__________ Disability Status__________ Partner/Relationship Status__________ Martial Status__________

For how long? __________________ Spouse/Partner’s Name ____________________________________________ 
Age ______ Occupation _____________________________________________

List Children (Child’s Name Age Gender):
________________________      ________________________    ________________________ 

List the people in your household (Person/Relationship): 
________________________      ________________________    ________________________ 

GENERAL MENTAL HEALTH / MEDICAL HISTORY
Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc.)? Yes No 


Have you ever been prescribed psychiatric medication? Yes No 
       If so, list medications and dates _____________________________________________________________________


Are you under the care of a psychiatrist currently? Yes No 
If so, provider’s name _________________________________________ Phone number (____)___________________ 


Have you ever been treated for substance abuse? Yes No When? ___________________________________
Are you currently being treated for substance abuse? Yes No Where? ________________________________ 
Have you ever been hospitalized for emotional problems? Yes No 

If so, when? ____________________________________ Facility name _______________________________________


Do you have, or have you 
had, any of the following:                  Yes No                     If so, please describe briefly below:
Depression                                                                        ___________________________________________
Anxiety                                                                              ___________________________________________
Bipolar Disorder                                                                ___________________________________________

Panic Attacks                                                                    ___________________________________________ 
Phobias                                                                             ___________________________________________    
Eating Disorder                                                                 ___________________________________________
Insomnia                                                                           ___________________________________________
Alcohol/Drug Abuse                                                          ___________________________________________
Suicide Attempts                                                               ___________________________________________
Chronic Pain                                                                     ___________________________________________

Please list any and all health problems you are currently being treated for by a physician: ________________________________________________________________________________________________ ________________________________________________________________________________________________

Is there anything else you want me to know about your physical or emotional health? ________________________________________________________________________________________________ ________________________________________________________________________________________________

FAMILY MENTAL HEALTH HISTORY 


Does anyone in your family 
have any of the following:                  Yes No                     If so, please describe briefly below: 
Depression                                                                        ___________________________________________
Anxiety                                                                              ___________________________________________
Bipolar Disorder                                                                ___________________________________________
Schizophrenia                                                                   ___________________________________________

Panic Attacks                                                                    ___________________________________________ 
Phobias                                                                             ___________________________________________    
Eating Disorder                                                                 ___________________________________________
Suicide/Attempts                                                               ___________________________________________
Alcohol/Drug Abuse                                                          ___________________________________________
Domestic Violence                                                            ___________________________________________