Client Information

(*) denotes required fields

Name	Purpose	Dose
* Name:
* Address:
* Primary Phone:
Messages?	Yes / No
Alternative Phone:
Messages?	Yes / No
* Email:	*Confidentiality Limits
Skype:	Online Clients
* Age:
* Date of Birth:
* Relationship/Marital Status:
Anniversary Date:
Children
	Name	Age
Child #1
Child #2
Child #3
Child #4
Child #5

Place of Employment:
Position Held:
* Emergency Contact:
Emergency Contact Address:
* Emergency Contact Phone:
Messages?	Yes / No
Emergency Contact Relationship to you:
* Physician:
Physician Address:
* Physician Phone:
How did you get my name?
If online, what search words did you use:
Prior Life Experience Which of the following have you experienced (either currently or in the past)? Please check all that apply.
Physical Abuse
Death of a Close Family Member
Drug or Alcohol Abuse
Sexual Assault/Abuse
Concerns About Eating/Food
Parents Separation/Divorce
Panic Attacks
Attempted Suicide
Depression
Difficulty in Intimate Relationships
Physical Health Concerns
Other Significant Concerns
Which of the above continue to be a problem for you?
Do you have current concerns about alcohol use?	Yes / No
Do you have concerns about illegal drug use?	Yes / No
Do you overuse prescription medication?	Yes / No
Do you have concerns with gambling?	Yes / No
Do you have concerns with Internet porn use?	Yes / No
Are you currently taking any medication?	Yes / No
If you answered the last question above "yes", please list them below:



Previous Therapy Experience
Have you seen a therapist in the past?	Yes / No
Date:
Purpose:
Was it helpful?
Goals for Therapy
What are your main concerns/issues?
How long have you been concerned about this?
What are your goals for therapy?
What concerns, if any, do you have about being in therapy?
* Do you agree that all the information you provided above is true?

Client Information

Children

Prior Life Experience

Previous Therapy Experience

Goals for Therapy