New Client Background Information Questionnaire

New Client Background Information Questionnaire

Date: ______

General Information

Name: ______Gender: ___(Male) ___(Female)

Phone: Home: ______Work: ______Cell:______

Address: ______

City______State ______Zip______

Social Security #: ______Date of Birth: ______Age: ______

*Emergency Contact Name: ______Relationship to you? ______

*Emergency Contact Phone:______

How may I contact you? ___ At home ____ At work ____ Other: ______

Living Arrangements: ___Own ____Rent ___ Other (explain): ______

How long at present address? ______Number of addresses in last 10 years?______

Marital Status (circle one): Single Engaged Married Separated Divorced Widowed Remarried

Circle last year of school completed: 9 10 11 12 GED College: 1 2 3 4 Other: ______

Are you currently employed? Yes / No If yes, name of employer: ______

Reason for today’s appointment?

______

Who referred you? ______

Please check any current experiences below:

_____ Abuse (___mental/emotional ___ physical ____sexual) _____ Neglect _____Abandonment

_____Adoption ___Abortion ___ Miscarriage ___Death of a loved one ___ Financial hardship

___ Homelessness ___ Career/Job Loss ____ Major Illness

___Other Major Trauma, please briefly describe below: ______

______

Use of Substances: ______Alcohol _____Street Drugs ____Prescription Medication

General: ____Eating Problems (too much or too little) ____Depression ____ Sexual Issues ___ Fear

____Nightmares _____Anxiety _____ Sleeping Problems ____ Anger ____Irritability ____Hearing

voices _____ Hallucinations ___ Mood Swings ____ Other, please explain ______

______

Relationship(s) with: ____Spouse _____Children ______Parents ______In-Laws

______Co-workers _____Friends ______Partners ______Other ______

Health Information

Do you have a physician? Yes______No______

Name______Phone Number: ______

Address: ______

Are you taking any prescription drugs? Yes ______No______

If yes, please write the medication name and for what purpose you are taking it:

______

Who prescribed the medications? ______

Do you think they are effective: ___ Yes ___ No

How often do you see this doctor? ______

Describe your physical health: ____ excellent ____ good ___ fair ___ poor

Are you currently having any health problems that you think are significant? ___ Yes ___ No

If yes, please describe: ______

______

Date and results of last physical examination: ______

Your approximate height: ______Your approximate weight: ______lbs.

Have you ever had surgery? If yes, for what reason? ______

______

Have you ever been hospitalized for mental illness or substance abuse? ____Yes _____ No

If yes, please explain______

______

Are you currently seeing any other medical professionals? (Physical Therapist, Massage Therapist, Acupuncturist, Chiropractor, etc.) Yes ______No______If yes, for what purpose ______

Any recent changes in weight (gain or loss)? Yes ____ No _____ If yes, please explain: ______

On average, how many hours of sleep do you get per night? ______

Any recent changes in sleeping patterns? Yes____ No____ If yes, please explain: ______

______

Do you drink alcohol? Yes ____ No _____ If yes, how often? ______How much do you consume on average?______

Age at first use of alcohol: ______Date of last alcoholic drink: ______

Do you smoke cigarettes? Yes ____ No ____ If yes, how often do you smoke? ______How many cigarettes on a daily basis? ______

Have you ever used other substances such as Marijuana, Crack, Meth, Spice, etc.? Yes____ No_____ If yes, how often? ______Age began using? ______Date of last time you consumed the substance of choice? ______

List any significant present or past illnesses, injuries or disabilities: ______

______

If you are an adult, were you ever tested and /or diagnosed with any learning difficulties while in school? Yes____ No _____ If yes, please describe the results ______

______

If you are a child or teen, have you been tested and /or diagnosed with any learning difficulties while in school? Yes____ No _____ If yes, please describe the results ______

______

Have you ever attempted suicide? Yes ____ No _____ If yes, please explain when and how ______

______

Do you currently have thoughts of suicide? Yes ____ No _____ If yes, have you made a plan? Yes____ No____ If yes, please explain your plan ______

______

Has any close relative(s) attempted or successfully committed suicide? Yes ____ No ____

If yes, please share whom and when: ______

______

Does your past history include any of the following? Please check all that apply:

___Sexual abuse/Incest ___Physical abuse ___ Emotional abuse ___Abandonment

___Sexual addiction ___Child of Alcoholic Parent ___Gambling addiction ___Domestic violence

___Death of a close person ___Incarceration/Parole ___ Foster care ___Adoption

___Suicide Attempts/Ideation ___Divorce ___Marital separation ___Divorce of parents

___Eating disorder ___ Neglect ___Sleep disturbance ___Depression ___Trauma (physical/emotional)

___Rape ___ Self-mutilation ___ Mental Illness-Type______

Marital Information (If applicable)

Name of Spouse: ______Spouse's Age: ______Phone #: ______

Address of Spouse: ______

Spouse's Occupation: ______Work Phone #: ______

Religious preference of spouse: ______

How long did you know spouse before marriage? ______

Length of engagement? ______Date of Marriage: ______

Ages when married: Yours ______Spouse's ______

Any separation with your present spouse? Yes ____ No ____If yes, when and for what reason(s): _____

______

Has either spouse ever filed for divorce? Yes ____ No____ If yes, who filed and when? ______

______

Information about children from present marriage:

Name Age Gender Education Marital Status, if appropriate

______

Give brief information about any previous marriages, including children from previous marriages:

______

Indicate the amount of happiness you experience in your marriage and how happy you think your spouse is by checking a percentage for each of you below:

My happiness is about: My spouse's happiness is about:

__ 95% or better __ 95% or better

__75% __ 75%

__50% __50%

__25% __25%

__10% or less __10% or less

How committed are you to the marriage, and how optimistic are you that the marriage will improve?

______

Is your present sex life satisfactory? Yes ____ No ____ If no, please explain: ______

______

How are conflicts handled within your marriage? ______

______

Has there ever been any violence or threats of violence in your marriage? Yes ____ No ____

If yes, please explain: ______

______

Family History Information

Are your parents living or deceased? Father ______Mother ______

If living, present ages: Father ______Mother ______

If deceased, age at and cause of death: Father ______

Mother ______

If you have lost a parent or other close family through death, give information about your age and reaction at time of death: ______
______

Give a description of your father's personality and how he treated you and other family members: ______

Give a description of your mother's personality and how she treated you and other family members: ______

If you were raised by someone other than your natural parents, briefly explain who and describe their personality:______

List all the children in your natural family, from oldest to youngest, including yourself:

Name Age Gender Marital Status Career Status

______

Were your parents divorced/separated? Yes ____ No ____ If yes, how old were you and how did you react? ______

______

Why did the divorce or separation occur? _______

With which parent did you live? ______

Describe your home environment: ______

Religious and Spiritual Information

Church Name Member? Yes No

Religious/Denominational Preference:______

Do you attend services? ______regularly ______occasionally _____never

What does "spiritual" mean to you? ______

______

Identify any religious/spiritual questions or problems that are of concern to you: ______

______

Integration of Faith in Counseling Process

Please check below to describe how important your faith/spirituality is to you in your life:

_____ Significant ______Moderate ______Very little ______Not at all

*Please check your desire for an integration of your faith/spirituality in counseling: Yes ____ No _____

*Please check your desire for prayer to be a part of the counseling process: Yes ____ No _____

Personality Information

As you see yourself, what kind of person are you? Describe yourself. ______

If I were to ask other people to describe you, what five words would come up most frequently?

What are your four greatest fears?
a.

Identify any irrational, negative, or "horrible" thoughts that bother you: ______

Identify any habits or behaviors that you would like to change: ______

State in your own words what you consider to be the nature of your main problem(s): ______

Describe when and how your problem(s) began: ______

I estimate the severity of my problem(s) to be: (check only one) _____ just an irritant _____ mildly upsetting ______very severe______extremely severe ______totally incapacitating

Up to this point, what have you done about it? ______

What do you expect the counselor to do for you? ______

Have you sought other professional help with this problem? Yes ____ No ____

If yes, give name(s) and professional title(s) of the therapist(s), dates of treatment(s), and results: ______

List three goals you have for self-improvement:

List four major strengths or abilities: