Client Information Form

Your name

Your email

Your date of birth:

Describe your relationship status, eg. single, married etc:

Partner's name (if applicable)

Children's names and DOBs

Have you previously received treatment of any kind for mental health issues?
yesno
If yes please give details:

Are you taking any prescription medications? yesno If yes, please provide name, dosage and frequency

General Health Information

How would you rate your current physical health?
goodokunsatisfactorypoor
Please list any specific health problems you are currently experiencing:

How would you rate your current sleeping habits?
very goodgoodokunsatisfactorypoor
Please list any specific sleep problems you are currently experiencing:

How many times per week do you generally exercise?
What kind of activities do you engage in?

Please list any difficulties you experience with your appetite or eating patterns:

Are you currently experiencing overwhelming sadness, grief, or depression? yesno If so, for how long?

Are you currently experiencing anxiety, panic attacks, or have any phobias? yesno If so, please specify and tell me when this began.

Are you currently experiencing any chronic pain? yesno If yes, please describe:

How often do you drink alcoholic beverages?
dailyweeklymonthlyinfrequentlynever
Please add anything you feel I should know:

How often do you engage in recreational drug use?
dailyweeklymonthlyinfrequentlynever
Please add anything you feel I should know:

Are you currently in a romantic relationship? yesnoIf so, for how long?:

On a scale of 1-10, how would you rate your relationship? (10 is perfect!)

What significant life changes or stressful events have you experienced recently?

FAMILY MENTAL HEALTH HISTORY:
In the section below, identify if there is a family history of any of the following. If yes, please indicate the family member’s relationship to you in the space provided (father, grandmother, aunt etc)

Alcohol/Substance Abuse yesno Relationship to you:

Anxiety yesno Relationship to you:

Depression yesno Relationship to you:

Domestic Violence yesno Relationship to you:

Eating Disorders yesno Relationship to you:

Obesity yesno Relationship to you:

Obsessive Compulsive Behavior yesno Relationship to you:

Suicide Attempts yesno Relationship to you:

Schizophrenia yesno Relationship to you:

ADDITIONAL INFORMATION:

Are you currently employed?
yesno

If yes, Do you enjoy your work? Is there anything stressful about your current work?

Do you consider yourself to be spiritual or religious? yesno

If so, please elaborate:

What do you consider to be some of your strengths?

What do you consider to be some of your areas for development?

What would you like to accomplish out of your time in therapy?

Is there anything else you would like to add (optional)

Δ