1
New Client Information
Please fill out the form and either email it to me or bring it with you to your first session.
Personal History
1)Name:______2) Age:______3) Gender: ______
(Last) (First) (Middle)
4) Address:______
Street & NumberCityStateZip
5) Social Security Number: ______6) Insurance: ______
7) Insured Person’s Name: ______8) Insured’s DOB: ______
9) Date: ______10) Date of Birth: ______11)Yearsof Education:______12)Occupation:______
13) Home Phone: ______14) Cell/Other Phone: ______
15) Email:______
16)Marital status: ______If married, are you living with your spouse at present? ___
17)If married, years married to present spouse: ______
Counseling History
18)Are you receiving counseling services at present? ______
If yes, please briefly describe: ______
19)Have you received counseling in the past? ______
If yes, please briefly describe: ______
20)What is the main reason for your visit? ______
21)How long has this problem persisted (from #20)? ______
22)How did you hear about this practice, or who referred you?______
Medical History
23)Name and address of your primary physician:______
24)List any major illnesses and/or operations you have had: ______
25)List any physical concerns you are having at present: (e.g., high blood pressure, headaches,
dizziness, etc.):
26)List any other physical concerns you have experienced in the past: ______
27)When was your most recent complete physical exam? ______
Results of physical exam: ______
28)On average how many hours of sleep do you get daily? ______
29)Do you have trouble falling and/or staying asleep at night? ______If Yes, describe: ______
30)Have you ☐gained or ☐lost over ten pounds in the past year?______
If yes, was it intentional? ______
31)What medications (and dosages) are you taking at present, and for what purpose?
______
Have you ever been prescribed psychotropic medication? ______
Please list and provide dates: ______
Religious Concerns (if any)
32)What is your present religious affiliation? (Needed to help understand dynamics of your life.)______
Abuse History
33)Is there a history of physical or emotional abuse? ______
34)Is there a history of sexual abuse? ______
Family History
35)Mother’s age: ______If deceased, how old were you when she died? ______
36)Father’s age: ______If deceased, how old were you when he died? ______
37)If your parents are separated or divorced, how old were you then? ______
38)Number of Brother(s) ______Their Ages: ______
39)Number of Sister(s) ______Their Ages: ______
40)I was child number ______in a family of ______children.
41)Were you adopted or raised with parents other than your natural parents? ______
42)Briefly describe your relationship with your brothers and/or sisters: ______
43)Describe the family in which you grew up in terms of how everyone got along, resolved conflict, etc: ______
44)Describe how you were raised in terms of whether you were allowed to be independent or whether you felt controlled: ______
YOUR MOTHER (or mother substitute)
45)Briefly describe your mother: ______
46)How did she discipline you? ______
47)How did she reward you? ______
48)How much time did she spend with you when you were a child? (minimal, average, a lot, excessive, etc.): ______
49)Your mother’s occupation when you were a child: ______
50)How did you get along with your mother when you were a child?
☐ poorly☐ average☐well
51)How do you get along with your mother now?
☐ poorly☐average☐ well
52) Did your mother have any problems (e.g., alcoholism, mental health issues, etc.) that may have affected your childhood development? ______
(If yes, please describe): ______
53)Is there anything unusual about your relationship with your mother?______
(If yes, please describe): ______
54)Describe overall how your mother treated the following people as you were growing up:
You: ______
Your siblings: ______
Your father: ______
YOUR FATHER (or father substitute)
55)Briefly describe your father: ______
56)How did he discipline you? ______
57)How did he reward you? ______
58)How much time did he spend with you when you were a child? (minimal, average, a lot, excessive, etc.): ______
59)Your father’s occupation when you were a child: ______
60)How did you get along with your father when you were a child?
☐ poorly☐ average☐well
61)How do you get along with your father now?
☐ poorly☐average ☐ well
62)Did your father have any problems (e.g., alcoholism, mental health issues, etc.) that may have affected your childhood development? ______
(If yes, please describe): ______
63)Is there anything unusual about your relationship with your father? ______
(If yes, please describe): ______
64)Describe overall how your father treated the following people as you were growing up:
You: ______
Yoursiblings: ______
Your mother: ______
65) Is there a family history of any mental illness? If so, explain: ______
66) Describe what you consider to be your greatest strengths:
______
67)Describe what you consider to be your greatest weaknesses:
______
68)Describe any social difficulties that concern you: ______
69)Describe any love/sex/intimacy difficulties that concern you: ______
70)Describe your main difficulties at school or work:______
71)Describe your main difficulties at home: ______
72): Describe any behaviors that you would like to change: ______
73)What would you like to accomplish out of your time in therapy? ______