Client Information Form

Date:

Name: Gender:	Age: DOB:

Email Address:

Address: City: State: Zip:

Phone Number: Home:

OK TO LEAVE MESSAGE: Yes No Work:

OK TO LEAVE MESSAGE: Yes No Cell:

OK TO LEAVE MESSAGE: Yes No Other:

Single	Engaged Married Separated Divorced

Children:	None	Yes, complete below information

Name: Year of Birth:

Name: Year of Birth:

Name: Year of Birth:

Occupation: Years at current employment:

Education: Grades Completed/Degrees Earned:

Referred to this office by:

Are you currently seeing a mental health professional:	Yes	No

Have you had mental health services in the past:	Yes	No

If you have had mental health services, what did you like and not like about the experience?

Presenting Issues and Concerns

Briefly describe the reason you are seeking counseling.

What do you hope to gain from therapy?

Medical History

Do you have a primary physician? Yes No	If yes, name Phone

Have you ever had any major surgery, illness, accidents or hospitalizations? Yes No

Taking any prescription or over-the-counter medication presently? Yes No

If yes, what?

Any medication taken while in previous counseling?	Yes No

If yes, what?

For what diagnosis?

Treating Physician?

Have you had any weight changes recently? Yes No Need to discuss

Have you noticed any loss of appetite or any other eating issues? Yes No Need to discuss

Do you have any tension and/or pain in your body? Yes No Need to discuss

Do you have any nightmares or dreams that disturb you? Yes No Need to discuss

If yes, please describe:

Do you have a history of headaches or migraines? Yes No Need to discuss

If yes, please describe.

Do you drink alcoholic beverages? Yes No Need to discuss

If so, how many per day/week/month?

Any loss of interest in purpose, social activities, exercise, etc.? Yes No Need to discuss

If yes, please describe.

Do you ever experience anxiety or panic attacks of any kind? Yes No Need to discuss

If yes, please describe.

Are you unable to relax? Yes No Need to discuss

Are you over-ambitious? Yes No Need to discuss

Are you often “low” or “depressed”? Yes No Need to discuss

Are you often fatigued or without energy? Yes No Need to discuss

Ever had a severe emotional break? Yes No Need to discuss

Have you ever had hallucinations? Yes No Need to discuss

Have you had suicidal thoughts? Yes No Need to discuss

Do you feel unworthy or have low self-esteem? Yes No Need to discuss

Do you often feel guilty or regretful? Yes No Need to discuss

Please describe any additional issues that have not been covered in this form that you feel may be significant for your therapy?

Financial Policy

Payment is due at the beginning of each session. Any changes to the time of payment must be mutually agreed upon. A 24-hour notice is required for cancellations. Except for unforeseen circumstances, such as emergencies, you will be charged full fee for any cancellation without a 24-hour notice.

I understand and give my consent to be billed for any sessions scheduled if I do not notify the clinician at least 24 hours prior to any appointment.

I have read and understand the financial policy and accept the terms of my financial responsibility.

Client Signature	Date

*By digitally signing, I am acknowledging my agreement with and accuracy of information on this document. I may be asked to initial this document during my first session as well.