Confidential Client Information Form
Date *
Today's date
MM
/
DD
/
YYYY
Urgency *
How urgent is your need for a counseling appointment?
Emotional difficulty *
How emotionally difficult is it for you to request this appointment?
Your answer
Untitled Title
Personal Information
Name *
First and last name(s)
Your answer
Age *
Your answer
Marital status *
Marital Length
If married, how long?
Your answer
People living in your home *
Please provide names, ages and relationships of all
Your answer
Contact Information
Address *
Street address, city, state and zip code
Your answer
Primary phone *
Please provide the best phone number to use for reaching you
Your answer
Primary email *
Please provide the best email address to use for reaching you
Your answer
Being contacted *
When and how do you prefer to be contacted?
Your answer
It is OK... *
Required
Emergency contact *
Please provide name, relationship and phone number for an emergency contact
Your answer
The Problem, Concern or Issue
Suicidal *
Are you actively suicidal?
Causing harm *
In the last two weeks, have you feared that you might harm yourself or someone else?
Reason for counseling *
Please explain your reason for seeking counseling
Your answer
Duration *
How long has this been an issue (e.g., days, weeks, months?)
Your answer
Goals/Hopes for counseling *
What are your goals and/or hopes for counseling?
Your answer
Likely involvement *
Will the situation likely involve the legal system, medical assistance and/or pastoral help? Please specify.
Your answer
Severity *
Please rate the severity of your present concerns by checking one of the following:
Present concerns *
Please indicate which of the following areas are currently problems for you, check all that apply
Required
Medical Information
Previous counseling *
Have you previously seen a counselor / therapist / psychologist?
Previous counseling information
If you answered yes to the above, please provide the name of the counselor and the date of your last appointment
Your answer
Previous counseling results
If you answered yes to the above, please describe how you feel about the results of your previous counseling
Your answer
Previous counseling termination
If you answered yes to the above, please describe the reason for terminating previous counseling
Your answer
Previous psychiatric help *
Have you previously seen a psychiatrist?
Previous psychiatry information
If you answered yes to the above, please provide the name of the psychiatrist and the date of your last appointment
Your answer
Previous psychiatry results
If you answered yes to the above, and a diagnosis was made, please describe that here
Your answer
Suicide history *
Have you ever attempted suicide?
Family suicide history *
Has anyone in your family ever attempted suicide?
Other
How did you hear? *
How did you hear about New City Counseling? If a referral, please include their name.
Your answer
Availability *
When are you available to meet?
Your answer
Trinity attendance *
Do you attend Trinity Church?
Trinity membership *
Are you a member of Trinity Church?
Gender preference *
Do you have a preference in seeing a male or female therapist?
Your answer
Other
Is there anything else that your counselor should know before your first appointment?
Your answer
Agreement *
By typing "agree" in the box below, you acknowledge that you have reviewed the New City Counseling Agreement and agree to abide by it's stipulations. (please click on NCC Counseling Agreement at the bottom of the screen).
Your answer
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