Client Information

Email Address

Client Age [Years]

Client Gender

Marital Status

Children at home

Please list names and ages of children living in your household.

Other family at home

List other family members living in the household.

Unrelated persons at home

Please list any unrelated persons living in the household.

Emergency Contact Relationship

Indicate family relationships [mother, father, son, daughter, etc.] or non-family relationships [employer, friend, physician, etc.].

Insurance Information

Primary Insurance (if using EAP Benefits, please list the Company Name and Authorization Number instead of Policy ID)

Company Name

Policy ID

Group Number

Plan Name

Insured's Employer or School

Secondary Insurance

Company Name

Policy ID

Group Number

Plan Name

Treatments & Medications

Psychiatric Medications

If you have ever been prescribed psychiatric medications, please list them and provide the start and end dates.

Health & Mental Health Information

How would you rate your current physical health?

Current Health Issues

Please list any specific health problems you are currently experiencing.

Sleeping Habits

How would you rate your current sleeping habits?

Sleep Issues

Please list any specific sleep problems you are currently experiencing.

Exercise frequency

How many times per week do you generally exercise?

Types of exercise

What types of exercise do you participate in?

Eating Habits

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

Sadness, Grief, Depression

If you are currently experiencing overwhelming sadness, grief, or depression, please indicate for how long.

Anxiety, Panic, Phobias

If you are currently experiencing anxiety, panic attacks or have any phobias, please indicate for how long.

Chronic Pain

Please describe any chronic pain you are currently experiencing.

Additional Information

Describe your current job.

Describe any stressful aspects of your job.

Describe your current spiritual or religious faith or belief if applicable.

What do you consider to be some of your strengths?

What do you consider to be some of your weaknesses?

What would you like to accomplish during your course of therapy?

Alcohol Consumption

How often do you drink alcoholic beverages [wine, beer, mixed drinks, cocktails, etc.]?

Recreational Drug Use

How often do you engage in recreational drug use?

Romantic Relationship Status

If you are currently in a romantic relationship, how would you rate it on a scale of 1 [very weak] to 10 [very strong]?

Family Health History

Alcohol/Substance Abuse

If any member of your family has a history of alcohol/substance abuse, indicate their relationship to you [father, mother, grandfather, grandmother, uncle, aunt, etc.]

Anxiety

If any member of your family has a history of anxiety, indicate their relationship to you [father, mother, grandfather, grandmother, uncle, aunt, etc.]

Depression

If any member of your family has a history of depression, indicate their relationship to you [father, mother, grandfather, grandmother, uncle, aunt, etc.]

Domestic Violence

If any member of your family has a history of domestic violence, indicate their relationship to you [father, mother, grandfather, grandmother, uncle, aunt, etc.]

Eating Disorders

If any member of your family has a history of eating disorders, indicate their relationship to you [father, mother, grandfather, grandmother, uncle, aunt, etc.]

Obesity

If any member of your family has a history of obesity, indicate their relationship to you [father, mother, grandfather, grandmother, uncle, aunt, etc.]

Obsessive/Compulsive Disorder

If any member of your family has a history of Obsessive/Compulsive Disorder, indicate their relationship to you [father, mother, grandfather, grandmother, uncle, aunt, etc.]

Schizophrenia

If any member of your family has a history of schizophrenia, indicate their relationship to you [father, mother, grandfather, grandmother, uncle, aunt, etc.]

Suicide

If any member of your family has a history of suicide or attempted suicide, indicate their relationship to you [father, mother, grandfather, grandmother, uncle, aunt, etc.]

Additional Comments

Please add any further information that may be helpful in understanding your medical condition and history.

New Client Information