About
Counseling
Resources
Appointments
About
Counseling
Resources
Appointments
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Personal Information
Client Name
First
Last
Date
Date Format: MM slash DD slash YYYY
Age
Date of Birth
Date Format: MM slash DD slash YYYY
Gender
Male
Female
Form completed by (if someone other than the client):
Address
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone (home)
Phone (work)
Please provide any additional information here.
Primary reason(s) for seeking services.
Anger Management
Eating Disorder
Sleeping Problems
Anxiety
Fear/Phobias
Addictive Behaviors
Coping
Mental Confusion
Alcohol/Drugs
Depression
Sexual Concerns
Other Mental Health Concerns
Specify the other mental health concerns here
Marital Status (more than one answer may apply)
Single
Legally Married
Widowed
Divorce in process
Separated
Annulment
Unmarried, living together
Divorced
Length of time legally married
Length of time widowed
Length of time divorced in progress
Length of time seperated
Length of time living together, unmarried
Length of time divorced
Total Number of Marriages
Assessment of current relationship (if applicable):
Good
Fair
Poor
Development
Are there special, unusual, or traumatic circumstances that affected your development?
Yes
No
If yes, please describe:
Has there been history of child abuse?
Yes
No
If yes, which type(s)?
Sexual
Physical
Verbal
If yes, the abuse was as a:
Victim
Perpetrator
Other childhood issues:
Neglect
Inadequate Nutrition
Other (please specify)
Other childhood issues
Additional Comments:
Spiritual/Religious
How important to you are spiritual matters?
Not
Little
Moderate
Much
Are you affiliated with a spiritual or religious group?
Yes
No
If Yes, describe:
Were you raised within a spiritual or religious group?
Yes
No
If Yes, describe:
Would you like your spiritual/religious beliefs incorporated into the counseling?
Yes
No
If Yes, describe:
Counseling/Prior Treatment History
Counseling/Psychiatric Treatment
Yes or No
When
Where
Your reaction to overall experience
Suicidal Thoughts/Attempts
Yes or No
When
Where
Your reaction to overall experience
Drug/Alcohol Treatment
Yes or No
When
Where
Your reaction to overall experience
Hospitalizations
Yes or No
When
Where
Your reaction to overall experience
Involvement with self-help groups (e.g., AA, Al-Anon, NA, Overeaters Anonymous)
Yes or No
When
Where
Your reaction to overall experience
Involvement with self-help groups (e.g., AA, Al-Anon, NA, Overeaters Anonymous)
Yes or No
When
Where
Your reaction to overall experience
Please check behaviors and symptoms that occur to your more often than you would like them to take place:
Aggression
Alcohol Dependence
Anger
Antisocial Behavior
Anxiety
Avoiding People
Chest Pain
Cyber Addiction
Depression
Disorientation
Distractibility
Dizziness
Drug Dependence
Eating Disorder
Elevated Mood
Fatigue
Gambling
Hallucinations
Heart Palpitations
High Blood Pressure
Hopelessness
Impulsivity
Irritability
Judgement Errors
Loneliness
Memory Impairment
Mood Shifts
Panic Attacks
Phobias/Fears
Recurring Thoughts
Sexual Addiction
Sexual Difficulties
Sick Often
Sleeping Problems
Speech Problems
Suicidal Thoughts
Thoughts Disorganized
Trembling
Withdrawing
Worrying
Other
If Other, please specify:
Briefly discuss how the above symptoms impair your ability to function effectively:
Additional Information
Any additional information that would assist us in understanding your concerns or problems:
What are your goals for therapy?
Do you feel suicidal at this time?
Yes
No
If Yes, please explain:
