Client Information Form 
Today’s date: _________________

Note: If you have been a patient here before, please fill in only the information that has changed. 

A. Identification 
Your name: ____________________________________________  Date of birth: __________________ Age: ____
Nicknames or aliases: ____________________________________ Social Security #: _________________________
Home street address: ________________________________________________________ Apt.: ________________
City: ___________________________________________________________  State: _____ Zip: _______________
Home/evening phone: ______________________________ e-mail: ________________________________________
Calls or e-mail will be discreet, but please indicate any restrictions: ________________________________________

B. Chief concern:
Please describe the main difficulty that has brought you to see me: __________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________

C. Referral:  Who gave you my name to call?
Name: ________________________________________________________ Phone: _________________________
Address: ______________________________________________________________________________________
May I have your permission to thank this person for the referral? ❑ Yes  ❑ No 

How did this person explain how I might be of help to you? ____________________________________________
____________________________________________________________________________________________

D. Religious and racial/ethnic identification
Current religious denomination/affiliation  ❑ Protestant	❑ Catholic	❑ Jewish ❑ Islamic	❑ Buddhist 	❑ Hindu
Other (specify): _______________________________________________
Involvement:  ❑ None   ❑ Some/irregular	❑ Active		
How important are spiritual concerns in your life? _____________________________________________________
Which (if any) church, synagogue, temple, or meeting are you involved with? _______________________________ 
Ethnicity/national origin: ______________________________ Race: _________________________ or other similar way you identify yourself and consider important: ___________________________________________________________

E. Your medical care: From whom or where do you get your medical care? 
Clinic/doctor’s name: ____________________________________________  Phone: _______________________ Address: ________________________________________________________________________________________
If you enter treatment with me for psychological problems, may I tell your medical doctor so that he or she can be fully informed and we can coordinate your treatment? ❑ Yes   ❑ No 

F. Your current employer 
Employer: ________________________________________ Address: _______________________________________
Work phone: _____________________________ or other means of communication ____________________________
Calls will be discreet, but please indicate any restrictions: _________________________________________________

G. Emergency information
If some kind of emergency arises and we cannot reach you directly, or we need to reach someone close to you, whom should we call?
Name: __________________________________  Phone: ____________________ Relationship: ________________
Address: _______________________________________________________________________________________
Significant other/nearest friend or relative not residing with you: ____________________________________________
Client Information Form (p. 2 of 7) 

H. Your education and training 
Dates Attended	School Name	Special Classes	Adjustment to School	Did You Graduate?	

					

					

I. Employment and military experiences 
				Dates	Name of Employer	Job Title or Duties	Reason for Leaving	

				

				

J. Family-of-origin history 
Relative	Name	Current Age
(or age at death)	Illnesses
(or cause of death)	Highest Education Attained	Occupation	
Father						
Mother						
Brothers						

						
Sisters						

Step-Parents						
						
Grandparents						

						
Uncles/Aunts						

						
Others						

						

K. Relationships in your family of origin. 
Please describe the following: 
1. Your parents’ relationship with each other: _____________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________

Client Information Form (p. 3 of 7) 

2. Your relationship with each parent and with any other adults present: _____________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________

3. Your parents’ medical problems, drug or alcohol use, and mental or emotional difficulties: ____________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________

4. Your relationship with your brothers and sisters, in the past and present: ___________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________

L. Abuse history: 
❑  I was not abused in any way. ❑  I was abused. 
If you were abused, please indicate the following. For kind of abuse, use these letters: P = Physical, such as beatings. 
S = Sexual, such as touching/molesting, fondling, or intercourse. N = Neglect, such as failure to feed, shelter, or protect. 
E = Emotional, such as humiliation, etc. 
Your age	Kind of abuse
(P,S,N,E)	By whom?	Effects on you?	Whom did you tell?	Consequences of telling?	

						

						

M. Marital/relationship history 
Spouse’s Name	Spouse’s age at time of marriage	Your age at time of marriage	Your age at time of seperation/divorce	Has your spouse remarried?	

					

N. Present relationships 
1. How do you get along with your present spouse or partner? ________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________

2. How do you get along with your children? _____________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________

O. Children Indicate those from a previous marriage or relationship with “P” in the last column. 
Name	Age	Sex	School	Grade	Adjustment Problems	P?	

							

							

Client Information Form (p. 4 of 7) 

P. Significant nonmarital relationships 
Person Name									Name of Person	Person’s age at beginning of relationship	Your age at beginning of relationship	Your age at termination of relationship	Reason for relationship ending?	

					

Q.	Treatment 
1. Have you ever received psychological, psychiatric, drug or alcohol treatment, or counseling services before? 
❑  No  ❑  Yes If yes, please indicate:

When?	Where?	For What?	What were the Results?	

				

				

2. Have you ever taken medications for psychiatric or emotional problems?  ❑ No   ❑ Yes If yes,please indicate: 
When?	Name of Physician	Name of Medication	For What?	What were the Results?	

					

					

R. Chemical use 
1. How many cups of regular coffee do you drink each day? _____ How many cups of tea? ____. How many sodas/pop with caffeine (Coke, Pepsi, Mountain Dew, Dr. Pepper, Orange Crush, etc.)? ____ How many “energy drinks”? ____ How often do you use No Doz or similar caffeine pills? _______ .
2. How much tobacco do you smoke or chew each week? __________________________________________________
3. Have you ever felt the need to cut down on your drinking?  ❑  No   ❑  Yes 
4. Have you ever felt annoyed by criticism of your drinking?  ❑  No   ❑  Yes 
5. Have you ever felt guilty about your drinking?  ❑  No  ❑  Yes 
6. Have you ever taken a morning “eye-opener”?  ❑  No   ❑  Yes 
7. How much beer, wine, or hard liquor do you consume each week, on the average? ______________________________
8. Are there times when you drink to unconsciousness, or run out of money as a result of drinking?  ❑  No   ❑  Yes 
9. Have you ever injected drugs?  ❑  No   ❑  Yes
10. Have you ever shared needles?  ❑  No   ❑  Yes
11. Have you ever used inhalants (“huffing”), such as glue, gasoline, or paint thinner?  ❑  No   ❑  Yes If yes, which and when? ________________________________________________________________________________________________________
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, how often you used them, their effects, and so forth: __________________________________________________________________________________________________
_________________________________________________________________________________________________________
__________________________________________________________________________________________________________

Client Information Form (p. 5 of 7)
 
S. Legal history 
1. Are you presently suing anyone or thinking of suing anyone?  ❑  No   ❑  Yes. If yes, please explain: _______________
______________________________________________________________________________________________________
______________________________________________________________________________________________________

2. Is your reason for coming to see me related to an accident or injury? ❑ No ❑ Yes If yes,please explain:  ________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________

3. Are you required by a court, the police, or a probation/parole officer to have this appointment? ❑ No ❑ Yes.  If yes, please explain: ________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________

4. List all the contacts with the police, courts,and jails/prisons you have had. Include all open charges and pending ones. Under “Jurisdiction,” write in a letter:F = federal,S = state,Co = county,Ci = city.
Under “Sentence,” write in the time and the type of sentence you served or have to serve (AR = accelerated or alternate resolution,CS = commu­nity service, F = fine, I = incarceration, Pr = probation, Po = parole, O = other, R = restitution). 

Date	Charge(s)	Jurisdiction
(F,S,C,Ci)	Sentence
(AR,I,Pr,Pa)	Probation/Parole Officer’s Name	Attorney’s Name	

						

						
						
5. Your current attorney’s name: ____________________________________________  Phone: _________________
6. Are there any other legal involvements I should know about? _______________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________

T. Medical History 
1. Starting with your childhood and proceeding up to the present, list all diseases, illnesses, important accidents and 
injuries, surgeries, hospitalizations, periods of loss of consciousness, convulsions/seizures, and any other medical 
conditions you have had. (Describe pregnancies in section E.) 
Age	Illness/diagnosis	Treatment received	Treated by	Result	

					

					

2. Describe any allergies you have. 
Allergic to what?	Reactions you have?	Allergy Medications you take?	

			

Client Information Form (p. 6 of 7)

3. List all medications, drugs, or other substances you take or have taken in the last year—prescribed, over-the-­counter vitamins, herbs, and others. 
Medication/Drug	Dosage	Taken for what?	Prescribing Physician	

				

				

4. Have you done any kinds of work where you were exposed to toxic chemicals? 
Dates	Kind of chemicals	Kind of work	Effects of chemicals	

				

U. Health habits 
1. What kinds of physical exercise do you get? ____________________________________________________________________
__________________________________________________________________________________________________________ __________________________________________________________________________________________________________

2. How much coffee,cola,tea,or other sources of caffeine do you consume each day? Which? _______________________________
_________________________________________________________________________________________________________

3. Do you try to restrict your eating in any way? 
How? ____________________________________________________________________________________________________
Why? ____________________________________________________________________________________________________

4. Do you have any problems getting enough sleep?  ❑ No ❑ Yes. If yes, what problems?  _______________________________
__________________________________________________________________________________________________________

V. For women only 
At what age did you start to menstruate (get your period): _______
2. Menstrual period experiences: 
a. How regular are they? ___________________________________________________________________________
b. How long do they last? __________________________________________________________________________
c. How much pain do you have? _____________________________________________________________________
d. How heavy are your periods? _____________________________________________________________________
e. Other experiences during periods? _________________________________________________________________
Please list all of your pregnancies: 
Your age	What happened with this pregnancy?	Problems with Pregnancy	
	Miscarriage	Abortion	Child born		

					

					

4. Menopause: 
a. If your menopause has started, at what age did it start? __________________
Client Information Form (p. 7 of 7)

b. What signs or symptoms have you had? ____________________________________________________________
_______________________________________________________________________________________________ _______________________________________________________________________________________________

M. Is there any other information you think we should know?

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This is a strictly confidential patient medical record. Redisclosure or transfer is expressly prohibited by law.