Kathleen L. Anderson, Licsw

KATHLEEN L. ANDERSON, LICSW

1800 – 112th Avenue NE, Suite 220W

Bellevue, WA 98004

(425) 452-0905

CLIENT INFORMATION

This form requests information about you (or your child), which will be helpful in planning my services for you. Please take a few moments to complete the form carefully. I appreciate your time and effort in completing these documents.

Name: ______Today’s Date: ______

Address: ______

Street

______

CityStateZip Code

Telephone: (______)______(______)______

Home OK to contact there? Y N Work OK to contact there? Y N

Emergency Contact: ______(______)______

Name Relationship to client Phone number

Age: ______Birth Date: ______SSN: ______

Relationship Status: ____ Single ____Married ____ Partnership ____Separated ____Divorced ____Widowed

Spouse’s Name: ______Age: ______Occupation: ______

Please list all other persons living in your household, their ages and relationship to you:

NameAgeRelationship

______

______

______

______

______

Education: ______Occupation: ______

Place of Employment: ______Years Employed: ______

How were you referred to me? ______

PRIMARY INSURANCE INFORMATIONSECONDARY INSURANCE INFORMATION

Insurance Company: ______Insurance Company: ______

Insurance Company Contact Phone:Insurance Company Contact Phone:

(______)______(______)______

Insured Name: ______Insured Name: ______

Insured SSN: ______DOB: ______Insured SSN: ______DOB: ______

Employer: ______Employer: ______

Member #: ______Member #: ______

Policy/Group #: ______Policy/Group #: ______

Client’s Relationship to the Insured:Client’s Relationship to the Insured:

____ Self ____Spouse ____ Dependent____ Self ____Spouse ____Dependent

MEDICAL INFORMATION

When were you last examined by a physician? ______

Name of your Primary Care Physician: ______

Physician’s Address: ______

StreetCityState Zip Code

May I contact your physician if necessary? Yes / No ______

Please Initial

List any major health problems for which you currently receive treatment:

______

______

List any medications you are now taking:

Medication Name:Date Began:Current Dose:

______

______

______

Please describe your reason(s) for seeking treatment at this time. Include when the problem started: ______

______

______

Have you ever received mental health or substance abuse treatment of any kind before? Yes / No

Provider NameReason for seeking helpFirst SeenLast Seen

______

______

______

PROBLEM LIST

Please indicate past problems with a “P” and current problems with a “C”.

_____ Depression_____ Chronic Illness_____ Marriage/Relationship Issues

_____ Anxiety_____ Chronic Pain_____ Sexuality/Sexual Issues

_____ Stress_____ Loneliness_____ Family Conflict

_____ Grief/Loss_____ Eating or Weight Problem_____ Behavioral Problems

_____ LD/ADHD_____ Abuse/Victimization_____ Schizophrenia/Psychosis

_____ Anger_____ Domestic Violence_____ Phobias/Fears

_____ Obsessions/Compulsions_____ Manic Episodes_____ Eliminating a drug/alcohol habit

_____ Trauma_____ Legal Matters_____ Eliminating another habit

(i.e., overspending, gambling)

Please indicate how the problems are affecting the following areas of your life:

LittleSomeMuchSignificantNot

No EffectEffectEffectEffectEffectApplicable

Marriage/Relationship 1 2 3 4 5 N/A

Family 1 2 3 4 5 N/A

Job/School Performance 1 2 3 4 5 N/A

Friendships 1 2 3 4 5 N/A

Financial Situation 1 2 3 4 5 N/A

Physical Health 1 2 3 4 5 N/A