(424) 835-1046
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Home
About
Benefits
Risks
Downloads
(424) 835-1046
Contact
Client Name
*
First Name
Last Name
Age
*
DOB
*
Date of Birth
MM
DD
YYYY
Telephone #
Work Phone
*
(###)
###
####
Home Phone
*
(###)
###
####
Address
Home/Work
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Driver's License
Ethnicity
Emergency Contact
Name
*
Relationship
*
Contact Phone #
*
(###)
###
####
Treatment
Please Describe Issues For Treatment
*
Description
Previous Therapy Experience
*
No Therapy Experience
Previous Therapy Experience
If you have previous therapy experience
*
Please describe length of treatment and whether or not you found treatment positive or negative
Employment
*
Full Time
Part Time
Student
Not Applicable
Employment Description
*
Please indicate a job description or the school and subject matter studied. If not applicable enter NA.
Educational Background
*
High School
College
Professional Degree (Please explain below)
Please explain if you have a professional degree
if none type in NA
Current Living Arrangement
*
Live Alone
Live with Others (specify below)
Please specify if you live with others
if not applicable type in NA
Where were you born and raised
*
Family Background
Parents
*
Married
Divorced
Never Married
Mother
*
please select only one
Alive
Deceased (enter year below)
Year Mother Deceased
Father
*
please select only one
Alive
Deceased (enter year below)
Year Father Deceased
Siblings
*
please select only one
Yes
No
Number of Siblings
Position in Family
Children
*
please select only one
Yes
No
Ages
Ages of your children
Please indicate your relationship with:
Father
Mother
Siblings
Children
Marital Status
*
Married
Single
Divorced
Separated
Support Network
Please indicate your satisfaction with the following possible supports
Friends
Family
Support Groups
Pets
Medical Information
Physical Health Rating
*
Excellent
Good
Fair
Poor
Medication Information
*
Taken Medications in the past
Currently taking medications
Current Medications Information
*
If taking any medications currently please let me know what.
Please indicate current or past medical conditions
*
Allergies/Adverse Reactions
*
Physician’s Name
*
Physician's Phone Number
(###)
###
####
Psychiatrist’s Name
Psychiatrist’s Phone Number
(###)
###
####
Drug and Alcohol Assessment
History of Drug/Alcohol Use
*
please select only one
Yes
No
Age Drug/Alcohol Use Started
*
Drugs Used
Current Drug/Alcohol Use
*
please select only one
Yes
No
Currently Using
*
Estimated Frequency of use
*
Are you involved in AA or NA
*
please select only one
Yes
No
Please Explain
Suicide Assessment
Current suicidal feelings
*
please select only one
Yes
No
Previous suicidal attempts
*
please select only one
Yes
No
Family history of suicide
*
please select only one
Yes
No
Past hospitalization
*
please select only one
Yes
No
Please explain
*
if you selected yes to any of the above in Suicide Assessment please explain here
Insurance
Insurance Company Name
*
Insurance Plan #
*
Is Insurance Under your name
*
please select only one
Yes
No
If not, insured name:
*
Insured SSN
*
Thank you!