New Client Information

Please send this form prior to your first session with Vicki.

Note: all information is protected as CONFIDENTIAL. See our HIPAA documentation for more.

Client Information
Client Name *
Client Name
May I contact you via email for non-confidential communication?
Client Address
Client Address
Client Date of Birth *
Client Date of Birth
Please list names and ages of children living in your household.
List other family members living in the household.
Please list any unrelated persons living in the household.
Client Home Phone
Client Home Phone
Client Mobile Phone
Client Mobile Phone
Emergency Contact Name *
Emergency Contact Name
Indicate family relationships [mother, father, son, daughter, etc.] or non-family relationships [employer, friend, physician, etc.].
Emergency Contact Phone
Emergency Contact Phone
Emergency Contact Alternate Phone
Emergency Contact Alternate Phone
Referred by
Referred by
Name of person referring you to Vicki, if applicable.
Insurance Information
Primary Insurance
Policy Holder Name
Policy Holder Name
Policy Holder Date of Birth
Policy Holder Date of Birth
Policy Holder Address
Policy Holder Address
Secondary Insurance
Policy Holder Name
Policy Holder Name
Policy Holder Date of Birth
Policy Holder Date of Birth
Policy Holder Address
Policy Holder Address
Employee Assistance Program [EAP]
EAP Available *
Do you have employee assistance program [EAP] benefits through your employer?
If you have EAP benefits available, enter the name of the provider of EAP benefits.
Enter the number of sessions authorized by your EAP provider.
Enter any authorization code from your EAP benefits provider.
Authorization Start Date
Authorization Start Date
Enter the date from which your EAP benefits are available.
Treatments & Medications
Prior Mental Health Services *
Have you previously received any kind of mental health servers [psychotherapy, psychiatric consultation, etc.]?
Enter the name of your most recent previous therapist/practioner, if applicable.
If you are taking any prescription medications, please list them here and indicate for how long you have been taking each one.
If you have ever been prescribed psychiatric medications, please list them and provide the start and end dates.
Health & Mental Health Information
Please list any specific health problems you are currently experiencing.
How would you rate your current sleeping habits?
Please list any specific sleep problems you are currently experiencing.
How many times per week do you generally exercise?
What types of exercise do you participate in?
Please list any difficulties you experience with your appetite or eating patterns.
If you are currently experiencing overwhelming sadness, grief, or depression, please indicate for how long.
If you are currently experiencing anxiety, panic attacks or have any phobias, please indicate for how long.
Please describe any chronic pain you are currently experiencing.
Have you ever been a victim of physical abuse? *
Have you ever been a victim of sexual abuse? *
Have you ever experienced significant trauma? *
Additional Information
Are you currently employed? *
How often do you drink alcoholic beverages [wine, beer, mixed drinks, cocktails, etc.]?
How often do you engage in recreational drug use?
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
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.]
If any member of your family has a history of anxiety, indicate their relationship to you [father, mother, grandfather, grandmother, uncle, aunt, etc.]
If any member of your family has a history of depression, indicate their relationship to you [father, mother, grandfather, grandmother, uncle, aunt, etc.]
If any member of your family has a history of domestic violence, indicate their relationship to you [father, mother, grandfather, grandmother, uncle, aunt, etc.]
If any member of your family has a history of eating disorders, indicate their relationship to you [father, mother, grandfather, grandmother, uncle, aunt, etc.]
If any member of your family has a history of obesity, indicate their relationship to you [father, mother, grandfather, grandmother, uncle, aunt, etc.]
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.]
If any member of your family has a history of schizophrenia, indicate their relationship to you [father, mother, grandfather, grandmother, uncle, aunt, etc.]
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.]
Please add any further information that may be helpful in understanding your medical condition and history.