Client Information


Name:___________________ Date of Birth: ________________ Today's Date: ________________

Telephone: _________________ e-mail: _______________________________________________

Address: ________________________________________________________________________

Soc.Sec.#: ________________ Emergency Contact (Name&Tel#): ___________________________

Do you live with anyone? circle: Y N. If Yes, with whom? ___________________________________

Are you employed? circle: Y N. If yes, what do you do for a living?____________________________

What led you to seek this appointment?________________________________________________

________________________________________________________________________________

What would you like help with?_______________________________________________________

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Are you in any current mental health treatment? (circle: Y N)

If yes, what type of treatment and with whom?

Individual Psychotherapy: __; Medication Treatment: __; Group Therapy: __;

Family Therapy: __; Couples Therapy: __; Other (describe): ________

Treating Clinician :_______________________________________________________________

What, if any, psychotropic medication do you take currently?

Name of medicine: ____________________________ Total daily dose: ____________________

Name of medicine: ____________________________ Total daily dose: ____________________

Name of medicine: ____________________________ Total daily dose: ____________________

Name of medicine: ____________________________ Total daily dose: ____________________

What other medicines do you take? (Include herbs, vitamins, pain meds, allergy meds, sleep aides,
muscle relaxants, anti-anxiety agents, etc.)

_______________________________________________________________________________

_______________________________________________________________________________

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Please describe all past psychiatric/psychological counseling treatment you have received.

Problem treated: _________________________ Type of treatment: ______________________

Treating Practitioner: _____________________ Approx. dates of treatment: _______________

Problem treated: _________________________ Type of treatment: ______________________

Treating Practitioner: _____________________ Approx. dates of treatment: _______________

Problem treated: _________________________ Type of treatment: ______________________

Treating Practitioner: _____________________ Approx. dates of treatment: _______________

Do you have any medical conditions for which you are currently being treated? Y N.

If yes, please describe: ___________________________________________________________

Please describe any medical conditions for which you have been treated in the past:

______________________________________________________________________________

How often do you use the following substances?

Cigarettes: ____ per day ____ per wk ____ per month ____per year (comment: __________)
Alcohol: ____ per day ____ per wk ____ per month ____per year (comment: __________)
Marijuana: ____ per day ____ per wk ____ per month ____per year (comment: __________)
Cocaine: ____ per day ____ per wk ____ per month ____per year (comment: __________)
Hallucinogens:__ per day ____ per wk ____ per month ____per year (comment: __________)
Other: ____ per day ____ per wk ____ per month ____per year (comment: __________)

Have you or anyone else ever thought that you "over used" any substances (recreational/
prescription)? Y N If yes, please describe:

_______________________________________________________________________________

Have you had any treatment (including AA or other 12 step programs) for substance abuse? Y N

If yes, please describe: ____________________________________________________________

Have you ever been hospitalized for mental health reasons? Y N

If yes, where, when, what for? (Please describe.)

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

Have you ever been hospitalized for medical reasons? Y N

If yes, where, when, what for? (Please describe.)

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

Have you ever tried to kill yourself? Y N

If yes, please describe what happened and how you got through that difficult period.

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

Have you ever been physically, sexually or emotionally abused? Y N

If yes, please describe what happened to you and how you have coped with the abuse, if possible.

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

Is there a history of mental illness, mental health treatment, substance abuse or substance abuse
treatment in your family? Y N

If yes, please describe the relative's relationship to you and their difficulty, if possible.

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

Is there any history of medical illness in your family? Y N

If yes, please describe the relative's relationship to you and their illnesses, if possible.

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

Are you currently involved in any law suits or legal difficulties? Y N

If yes, please describe briefly.

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

What other information is important for you to tell me to help me understand your current situation
better?

_______________________________________________________________________________

_______________________________________________________________________________

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Thank you for giving me this information on a written form. Although it is less personal than telling it to
me directly, it will save us time in the initial interview, and allow us to get started addressing your
issues as quickly as possible.

Lynn Martin