Adult Client Information

Today’s date: _________________

Identification 
Client name: ____________________________________________  Date of birth: _________________ Age: ______
Home street address: ________________________________________________________ Apt.: ________________
City: ___________________________________________________________  State: _____ Zip: ________________
Home phone: __________________ Cell phone: __________________ e-mail: _______________________________ 
Referral source:  How did you hear about me?_________________________________________________________
Medical care
Primary Care Physician: ____________________________________________  Phone: ________________________
Date of last physical examination: ________________________
Psychiatrist: _____________________________________________________  Phone: _________________________
Date of last visit: ________________________
Other Specialist: __________________________________________________  Phone: _________________________ 
Current employer or school
Name of employer/school: _________________________________________________________________________
Current occupation or area of study: ______________________________________________________ 
Length of time employed or enrolled in school:________________________________________________________
Title/Position: _______________________________________City:______________________
Highest level of education (grade/degree type):___________________________________

Family
Current spouse/significant other: ______________________________________________________________________
Children living with you (include ages): _________________________________________________________________
Prior spouse/significant other: ________________________________________________________________________
Children not living in your home: ______________________________________________________________________
Significant other/nearest friend or relative not residing with you: _____________________________________________
If you are in a relationship, please describe the nature of the relationship and months or years together.
_________________________________________________________________________________________________

Emergency information
If some kind of emergency arises and we need to reach someone close to you, whom should we call?

Name: __________________________________  Phone: ____________________ Relationship: ________________

Clinical Information
Primary concern
What brings you to counseling at this time? Is there something specific, such as a particular event? Be as detailed as you can. (Use back of this page to continue, if necessary) _________________________________________________________________________________________________
_________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________

Lifestyle

Do you drink alcohol? Describe type, amount, frequency._________________________________________________
Do you use recreational drugs? Describe type, amount, frequency. _________________________________________
Do you exercise regularly? Describe type, amount, frequency. _____________________________________________

Medical Concerns

Any current health concerns for which you are currently receiving medical treatment?
Dates: 			Treating Physician:					Reason:					Results:_____________ ___

Specify all medications and supplements you are presently taking and for what reason. If taking prescription medication, who is your prescribing MD? 
Please include type of MD, name and phone number if different from MD listed above.
___________________________________________________________________________________________
Dates:       Medication type: 			Dosage: 					Reason: 							Results:____

Mental Health Treatment History
Have you ever received psychological, psychiatric, drug or alcohol treatment, or counseling services before? 
❑  No             ❑  Yes If yes, please indicate:

Dates: 			Treatment Provider: 					Reason: 						Results:_____________  

Have you ever taken medications for psychiatric or emotional problems?  
❑ No   ❑ Yes If yes, please indicate: 

Dates:       Medication type: 			Dosage: 					Reason: 							Results:____

Have you ever received psychological testing, such as for ADHD?
Date of Evaluation: 			Treatment Provider: 						Results:__							__ 

Do you currently have suicidal thoughts or have had suicidal thoughts in the past?
❑ No   ❑ Yes If yes, please explain:_______________________________________________________________ 
 Have you ever attempted suicide?
❑ No   ❑ Yes If yes, please explain:_______________________________________________________________ 
Do you have thoughts or urges to harm others?
❑ No   ❑ Yes If yes, please explain:_______________________________________________________________ 
Have you ever been hospitalized for a psychiatric issue?
❑ No   ❑ Yes If yes, please explain:_______________________________________________________________ 
Is there a history of mental illness in your family?
❑ No   ❑ Yes If yes, please explain:_______________________________________________________________ 

Please check any of the following you have experienced in the past six months:
 
❑	Trouble concentrating	❑	Tearfulness or crying spells	
❑	Difficulty sleeping	❑	Anxiety	
❑	Excessive sleep	❑	Fear	
❑	Low motivation	❑	Hopelessness	
❑	Isolation from others	❑	Panic	
❑	Fatigue/low energy	❑	Increased appetite	
❑	Low self-esteem	❑	Decreased appetite 	
❑	Depressed mood	❑	Unexplained weight loss/ gain	

Please explain all items marked above: __________________________________________________________________________________________________________________________________________________________________________________________________

Legal history 
Are you presently suing anyone or thinking of suing anyone?  ❑  No   ❑  Yes. If yes, please explain: 
_______________________________________________________________________________________________
Is your reason for coming to see me related to an accident or injury? ❑ No ❑ Yes If yes, please explain:  ___________
______________________________________________________________________________________________
Are you required by a court, the police, or a probation/parole officer to have this appointment? ❑ No ❑ Yes.  If yes, please explain: __________________________________________________________________________________

Are there any other legal involvements I should know about? ____________________________________________
Goals and Expectations

What are your goals for counseling? What change do you want to see happen as a result of seeking counseling services?
_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

What are some of your expectations about your therapist?
_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Is there any other information you think I should know?
_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Thank you for taking the time to complete this information form.