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Jeff Palitz, LMFT - New Client Data Sheet
Welcome to Eastlake Community Counseling and thank you for entrusting me with your treatment. Please take some time to carefully complete this form. PLEASE only complete this form if you have already scheduled an appointment with Jeff Palitz, LMFT. If a question does not apply, please answer "NA." The following form serves several purposes. First, it provides me with valuable information that I will need in order to provide the best possible services to you. Second, it will allow us to focus on matters relevant to your life during your first session rather than collecting information. If you ever have any questions about the nature of your treatment or anything else about your care, please do not hesitate to ask.

NOTE: There is other new client paperwork required in addition to this form. Please read the email you receive from Jeff thoroughly for instructions.

***CONFIDENTIALITY NOTE: You are discouraged from completing this form on a public network or computer. If you would prefer to complete a paper version, please feel free to print this for and bring it with you to your first session. Although I have no reason to believe that your confidentiality will be at risk, and every effort will be made to protect the confidentiality of data submitted on this form, due to the nature of the internet, I cannot provide a 100% guarantee of your confidentiality when submitting this form. Completing this form on a home/private computer or network will increase the security of your data.
Client Information
Name *
Please provide the client's full legal name.
Your answer
Best phone number to reach you *
Your answer
Client's Age *
Gender *
Marital Status *
Occupation
Your answer
Education
Highest grade completed - Choose One
Emergency Contact *
Please list the full name and telephone number of an emergency contact
Your answer
Referred By *
Please indicate how you found Jeff Palitz, MFT
Reason for your visit *
Please give a brief description of why you have made an appointment
Your answer
Symptoms of Current Problem *
Please check all that apply (during the last two weeks)
Required
Alcohol/Drug/Other Substance Information
Drink coffee? *
Cups per day
Your answer
Cigarettes? *
Number per day
Your answer
Alcohol *
Drinks per day or per week (please indicate)
Your answer
Date of last drink
MM/DD/YYYY
Your answer
Street Drugs *
Please indicate type, amount and frequency of use (or N/A)
Your answer
Prescription Medications *
Please list the name, dosage and frequency of all current prescrptions
Your answer
Please indicate the impact of substance abuse (yours or someone else's) on your life *
No Impact
Severe Impact
Any past treatment for substance abuse? *
If "Yes," please elaborate.
Your answer
Family History of substance abuse? *
If "Yes," please elaborate.
Your answer
Psychological/Medical History
Family History of mental illness? *
If "Yes," please provide diagnosis (if known) and relationship to client.
Your answer
Have you ever seen a psychiatrist/psychologist/therapist? *
If "Yes," please provide the name of your provider, when the treatment took place and approximately how long/how many sessions.
Your answer
Any history of psychiatric hospitalization or inpatient treatment? *
If "Yes," please provide approximate dates and reason(s) for hospitalization/treatment.
Your answer
Any significant medical issues (past or present)? *
If "Yes," please elaborate.
Your answer
Date of last physical? *
Your answer
Currently pregnant?
Childbirth/new child in the last 12 months? *
Required
Please use this area to indicate any other relevant medical or psychological information.
Your answer
What do you see as your/client's strengths? *
Your answer
What do you see as your/client's weaknesses? *
Your answer
Goals for treatment. *
Please briefly describe what goals you hope to accomplish during your treatment.
Your answer
Any specific cultural or religious issues/needs?
Your answer
Please indicate the area(s) of your life impacted by or contributing to the current need for treatment. *
Check all that apply
Required
Please use this area to provide any additional information that you feel is relevant.
Your answer
ELECTRONIC SIGNATURE AND ATTESTATION
ANSWERING THE THREE QUESTIONS BELOW THIS PARAGRAPH CONSTITUTES YOUR ELECTRONIC SIGNATURE. By signing this document you are attesting that the information provided is true and complete to the best of your knowledge at the time it was completed.
Full Legal Name of Client or Client's Parent/Guardian (if client is a minor) *
Your answer
Signer's Relationship to Client *
i.e. Self, Mother, Father, etc.
Your answer
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