New Client Information Form
Please note, this form is for your review only. You cannot fill it out online. If you want to complete the form, you can download it here, print and fill it out.
New Patient Information Form
Please enter your information.
What is your preferred name? Pronouns:
Legal First Name: Middle Initial: Legal Last Name: Date of Birth:
Street Address: Apt./Unit #: City: State: Zip Code:
Mobile Phone: Can we leave a message at this number? Yes/No
Email:
Emergency Contact: Emergency Contact Phone: Relationship to Emergency Contact:
PRESENTING CONCERNS
Please explain what brings you to counseling:
How long has this been troubling you?
STRENGTHS
Tell us about your strengths, skills, abilities, and positive traits:
TREATMENT HISTORY
Have you ever participated in any form of counseling or treatment (e.g. mental health counseling, family/couples counseling, detox, substance abuse treatment, psychiatric medication maintenance, IOP, PHP, inpatient, etc.)? If so, please describe and include dates.
MEDICAL HISTORY AND SCREENING
How would you describe your current health?
Do you have any medical concerns?
When was your last physical exam?
Do you experience any difficulty with sleep (e.g. difficulty falling or staying asleep, troubling dreams, etc.)?
List all the medications you are taking (include dosage and when you take them):
HISTORY
Is there anything significant we should know about your developmental history? Examples include challenges with learning, accidents, injuries, experiencing unwanted touch, or other medical conditions that may have impacted your development. If yes, please describe.
FAMILY HISTORY
Please describe your family of origin (the family in which you grew up).
Please describe your current living situation/family (if different from your family of origin).
SOCIAL AND SPIRITUAL HISTORY
Who do you turn to for support?
Describe your current religious or spiritual belief practices.
EDUCATIONAL, VOCATIONAL AND FINANCIAL HISTORY
What was school like for you growing up?
What is the highest level of education you have completed?
Are you currently employed? If so, what is your job/career?
If you ever served in the military, describe your service (branch, rank, length of service, discharge type, disciplinary proceedings, etc.)
SUBSTANCE USE HISTORY
How old were you when you first experimented with drugs and/or alcohol?
Do you currently engage in drug and/or alcohol use? If yes, please describe your drug and alcohol use.
LEGAL HISTORY
Have you had any legal issues that may impact our work together?
My signature affirms that the information I have indicated here is true to the best of my knowledge.
Client Signature (age 12+):________________________________________________________ Date: ______________________