New Client Information
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Contact Information
Name *
Age *
Date of Birth *
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Email *
Is it OK to send you messages to this email? *
Phone Number *
Is it OK to leave voice/text messages to this phone number?
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City
Emergency Contact Name *
Emergency Contact Number *
Emergency Contact Relationship *
Presently Living With *
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Reasons for Seeking Therapy
What concerns have led you to pursue counseling?
What concerns are causing the most problems for you?
When did your present concern begin to be a problem for you?
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How are you currently managing? *
Have your concerns been noticed by others? *
How would you rate how serious this problem feels for you? *
Mildly upsetting
Extremely troubling
Please indicate which of the following areas are current problems for you
Sometimes
Often
Excessive anxiety or worry
Feeling lonely
Feeling sad/unhappy
Feeling angry
Suicidal thoughts/behaviors
Difficulty focusing or concentrating
Health issues
Loss of enjoyment and motivation
Problems with sleep
Troubling thoughts that are difficult to control
Relationship/marital challenges and conflict and problems
Financial concerns
Challenges dealing with past trauma
Feeling numb or cut off from emotions
Excessive fear or worry
Troubles with memory
Lacking self-confidence
Delusions or hallucinations
Obsessions or compulsions
Feeling stuck and hopeless
Shyness
Nervousness
Excessive stress
Have you been to counseling before
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How helpful did you find counselling?
Not helpful
Very helpful
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What was most helpful about counselling?
Medical/Health Information
Are you experiencing any physical problems or health concerns that we should know about?
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If yes, please describe your physical/health problems.
Please list your current medications.
How do you sleep?
Poorly
Very well
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Have you ever ben hospitalized for psychiatric purposes?
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If yes, please describe the reason for your hospitalization.
Please check any areas of family history that apply to you.
Father
Mother
Self
Siblings
Grandparents
Suicide
Substance abuse
Depression
Trauma
Anxiety
Alcohol problems
Drug problems
Anger/violence
Mental/emotional issues
Educational/Occupational Information
What is your highest level of education?
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Are you presently enrolled in school?
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If yes, what is your current field of study?
Are you currently employed?
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If yes, what is your occupation?
How satisfied are you with your job?
Unsatisfied
Very satisfied
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Is religion or spirituality important in your life?
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If yes, please briefly describe your religious/spiritual tradition or practice.
Please feel free to add anything else that you think we should know about you.
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