DOB:
Client Phone number:
Provider License: #83465
Marital Status:
If you are married, what is your spouse's name?
If you are married, what is your spouse's date of birth?
How many times have you been married?
Have you had any children?
If so, what are their names and ages?
With whom do you presently live?
Employment Place
How would you describe your current employment situation?
What is your level of education or highest degree and type?
What medical conditions do you currently have?
What medical conditions have you experienced in the past?
What medications, if any, are you currently taking? Include prescriptions, OTC nature remedies, and vitamins.
When was your last physical?
Who is your primary care physician?
Have you ever been prescribed medication for a psychiatric diagnosis?
If yes, please list any medications (even if you are no longer taking them).
Have you ever received the services of a professional counselor?
If so, please describe the nature of your prior visits
Please describe why you have chosen to seek counseling. What do you hope to gain from counseling?
Are you currently under the care of a mental health professional (counselor, psychologist, psychiatrist)?
If so, please list the professionals you currently see.
Do you or your family have any history of mental health issues (depression, anxiety, bipolar disorder, schizophrenia, personality disorder, eating disorders)?
Do you or your family have a history of substance abuse?
If so, please describe.
Is there any history of physical or sexual abuse against you?
Have you ever experienced something that you would consider traumatic?
Are you actively involved in a local church?
If so, how long have you attended your church?
Check all of the following that you have experienced in the last 6 months.
Today, I feel...
Growing up with my family was...
God is...
Fun for me is...
If I could change one thing...
Six months from now...
What else would you like me to know?
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