Confidential Client Information Form
Date
Today's date
MM
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DD
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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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