Client Information Please complete the form below, or print and fill out the PDF Client Information Form, and bring it to your first appointment. Please enable JavaScript in your browser to complete this form.Name *FirstLastDate of Birth *Social Security Number *Address *City *State *Zip Code *Phone Number *E-mail *Person to call in an emergency (Name and phone number) *Relationship to you (i.e., husband, sister) *Do I have your permission to contact your emergency contact if necessary? YesDo I have your permission to thank your referral source for the referral?YesIf referred by another clinician, would you like for us to communicate with one another?YesIf yes, please list the contact information for your referral sourcePresenting Problem - what has brought you here today (onset, duration, intensity and precipitating event if applicable)?Please check any of the following issues that pertain to youAnxietyStressAngerConcentrationDepressionSleep problemsMarital stressFinancesLonelinessAlcohol useDrug useFearsLegal mattersPainEating/foodCareer/workLoss/griefEnergyHealthSpiritual issueHIV/AIDSSexuality issuesAbuseTrauma historyCurrent traumaPanic attacksAttention/ADHDSuicidal thoughtsManiaParanoiaFamilial issuesSelf HarmingSchool issuesCommunication issuesEating DisorderSelf-esteem issuesPersonal growth goalsAddictive behaviorsPlease explain any significant medical problems, symptoms, or illnessCurrent medications (Please include dosing, schedule, physician.) Have you ever talked with a therapist in the past? If yes, why and for how long? (Please include any hospitalizations or treatment programs.)Are you currently seeing a psychiatrist? If yes, please list name and contact information.Are you at risk for hurting yourself or someone else? If yes, please explain, and address how you would like to see that changed.Do you use tobacco? If yes, please list amount/frequency of tobacco useDo you use alcohol? If yes, please list amount/frequency of alcohol useDo you use recreational drugs? If yes, please list type/amount/frequency of drug useHave you ever been treated for any form of substance abuse? If yes, please list time and duration and outcomeHave you ever had a DUI?YesNoAre there any current legal issues you are facing?YesNoPlease note here if you are on parole or probation or have any involvement with DFACS.How would you describe your relationship with your mother (current and past)?How would you describe your relationship with your father (current and past)?Are your parents still married or did they divorce? If they divorced, how old were you when the divorce happened?Were there any other primary caregivers who you had a significant relationship with? If so, please describe.How many siblings do you have? (Please list gender and ages.)Describe your relationship with your siblings (current and past)Relationships status (single, dating, divorced, engaged, married/life partner)If you’re in a relationship, for how long?Relationship satisfaction (1=poor, 5=excellent)12345Do you have children? (If yes, please list gender and ages.)To your knowledge, is there any history of addiction in your family?To your knowledge, is there any history of mental illness in your family?To your knowledge, is there a history of sexual, emotional, or physical abuse in your family?To your knowledge, is there a history of domestic abuse in your family?Is there anything else pertinent to your family history that would be important for me to know?Does your family support you in seeking help for your problems?What is your educational background? (GED, high school, college, graduate degree etc.)What is your current employment status?Are you currently on leave or seeking medical disability?YesNoAre you satisfied with your career currently?YesNoIf no, please explainWhat spiritual/religious affiliations do you have, if any?Do you have any sexual orientation or gender issues/concerns?What are your hobbies?Who is your support system?List your top 5 strengths as you see themAdditional CommentsWebsiteSubmit