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? ______