Aaron C. Glade, Ph.D., LMFT

Aaron C. Glade, Ph.D., LMFT

CLIENT INFORMATION SHEET

Date:______

YOUR Name:

Address: City State Zip______

Home Telephone:______Bus./Cell Telephone:

Age:______Date of Birth: ______Email:

Years of Education:______Highest Degree:

Place of Employment:

PARTNER'S Name:

Address: City State Zip______

Home Telephone:______Bus./Cell Telephone:

Age:______Date of Birth:______Email:

Years of Education:______Highest Degree:

Place of Employment:

· Years Together_____ Year Married______How Met

IF NOT MARRIED (Circle One): Separated Widowed Divorced Single Gay/Lesbian

Prior marriages: From ______to ______Whose marriage?______

If you have children, please give their names and ages (if not living with you, indicate where they are residing):

Do you now, or have you had, any physical illness or complaints? (Circle One) Yes No

If Yes, what?

Physician(s):

Current Medications you are taking and for what purpose(s):

If you belong to a religious organization, please indicate:

Church ______Pastor/Clergyperson

Has anyone in the family been in trouble with the law? (Circle One) Yes No

If yes, what was the incident, who was involved and at what age did it occur?

How much alcohol do you drink on a daily basis?

What participation do drugs, eating/not eating, or gambling play in your life

What role does sexuality play in why you are here?

Please indicate any individual(s) who you think may wish to confer with me during the course of your therapy (i.e., your physician, attorney, parent, children, etc.)

Were you referred by someone? (Circle One) Yes No If yes, by whom?

Referrals are a vital part of my practice. May I send a thank-you note to the above-named person(s) who referred you to me? If so, please sign and date below. Thank you.

Signature /
Date

If not referred, how did you hear of the Island MFT Clinic)? (If you heard about CCFH from the Yellow Pages, please indicate whether it was the Eastside or Northend Edition.)

What previous counseling experience(s) have you had and with whom?

What would be helpful for you to accomplish from your therapeutic experience?