CLIENT INFORMATION FORM

Identifying Information:
Name (First)_________________(Middle)_______________(Last)__________________
Address_____________________________________________________________________
City_____________________________State_________________________Zip__________
Date of Birth______________________________Age______________________________
Home Phone_______________Work Phone_______________Cell Phone________________
May I call you at home/cell?_____Leave messages?______With whom?____________
May I call you at work?_____Leave messages?______With whom?_________________

Employment/School:
Employer (or School)__________________________Position (Year)_______________
How long employed at this job?______________________________________________
What type of education/training have you had?_______________________________

Family:
Spouse/Partner______________________Age_______Length of Relationship________
List names/ages of children residing in home._______________________________
____________________________________________________________________________
List names/ages of children residing outside home___________________________
Other(s) living in home?____________________________________________________
Are your parents living?____________If so, where?___________________________
What family members have died?______________________________________________

Physical Health:
Primary Physician________________________Phone____________Last visit________
Other Current Physician(s)__________________________________________________
How would you rate your physical health?  Excellent___Good___Fair___Poor____
Medical Conditions/Concerns_________________________________________________
____________________________________________________________________________
What do you do to keep in good physical condition?__________________________
Allergies/Adverse Reactions:________________________________________________
Prescription Medications (include dosage, frequency, date prescribed): _____
____________________________________________________________________________
____________________________________________________________________________
Over-the-Counter Medications (include dosage, frequency): __________________
____________________________________________________________________________
Has your interest in food increased, decreased, or stayed about the same?___
Have you gained or lost weight recently?____________________________________
How frequently do you have trouble falling asleep?__________________________
How often do you wake up in the middle of the night and can't
go back to sleep?___________________________________________________________

Mental Health:
Do you use cigarettes?___alcohol?___Illicit drugs?___If so, what____________
Frequency of use:___________________________________________________________
Do you have a prior history of addiction or chemical dependency?____________
Did you receive treatment?______When?_______Where?__________________________
Have you sought professional counseling in the past?____When?_______________
Name of most recent mental health provider(s)_______________________________
What self-help programs (AA, Al-Anon, NA, grief groups, etc.)
have you attended?__________________________________________________________
What other resources for support (friends, family, pastor, etc.)
do you have?________________________________________________________________
What do you do to relieve stress?___________________________________________

Spiritual Health:
Do you believe in God or a Higher Power?____________________________________
What is your church or religious affiliation, if any?_______________________

What are your reasons for seeking counseling?_______________________________
____________________________________________________________________________
Who referred you?___________________________________________________________
Emergency Contact:_____________________________Phone________________________
Information and Guidelines reviewed? Yes_____No_____(Please initial)________
Privacy Polices reviewed? Yes_____No_____(Please initial)___________________

Signed____________________________________________Date______________________