New Clients (Sarah)

First Name (required)

Middle Initial

Last Name (required)

Nickname

Personal Email Address (required)

Gender
MaleFemale

Social Security Number (required)

Marital Status
MarriedSingleSeparatedDivorcedOther (explain)

Employment
EmployedFull-time StudentPart-time StudentUnemployed/Other

Mobile

No MessagesVoice MessagesText Messages

Home (required)

No MessagesVoice Messages

Work

No MessagesVoice MessagesText Messages

Preferred Phone (required)
-Select-MobileHomeWork

Health Insurance Company Name

Group #

Health Insurance ID #

Home Address (required)

Employer

Employer Phone

Employer Address

Occupation/Title/Position

Spouse Name (if applicable)

Spouse Home Address (if applicable)

Spouse Phone (if applicable)

Parent Name (if applicable)

Parent Home Address (if applicable)

Parent Phone (if applicable)

Name

Relationship

Date of Birth

Employer/School

Name

Relationship

Date of Birth

Employer/School

Name

Relationship

Date of Birth

Employer/School

Name

Relationship

Date of Birth

Employer/School

Have any of your biological relatives had concerns similar to yours, or had any other psychiatric or emotional difficulties? (required)
YesNo
If yes, which relatives and what kind of concerns/difficulties

Name

Phone Number

Relationship

Please describe briefly the concern or situation, which led you to seek services at this time (required)

How long has this been a concern? (required)

Have you experienced this type fo concern before? (required)
YesNo
If so, when?

Have you had any significant events, either positive or negative, occur recently or in a notable amount of time, such as job/school changes, death(s), changes in finances, living situation, illness, infertility, etc?

Physician Name

Physician Address

Physician Phone Number

Are you currently seeing a counselor, therapist, psychologist, or psychiatrist? (required)
YesNo
If yes, who?

Have you ever had counseling before? (required)
YesNo
If so, when and why?

Was it helpful?
YesNo
If not, why not?

Have you ever had medication prescribed for psychiatric or emotional difficulties? (required)
YesNo
If so, please list

Have you ever been physically, sexually, or emotionally abused? (required)
YesNo
If yes, briefly describe

Have you ever been hospitalized for mental or nervous problems? (required)
YesNo
If yes, when and where

Are you experiencing any issues related to sexuality (i.e. sexual identity, compulsive pornography use, desire, performance, etc.)? (required)
YesNo
If yes, please explain

Have you ever attempted suicide? (required)
YesNo
If yes, how and when?

Are you suicidal now? (required)
YesNo

How often do you drink alcohol? (required)

Have you ever been arrested for driving under the influence (DUI)? (required)
YesNo

Do you smoke or use tobacco? (required)
YesNo
If yes, how much?

Do you use recreational drugs? (required)
YesNo
If yes, what drugs do you use and how often?

Do you have any concerns about alcohol/drug usage by members of your family? (required)
YesNo
If yes, please explain

Are you currently involved or expected to be involved in any court related matters? (required)
YesNo
If yes, please describe

Do you consider yourself spiritual? (required)
YesNo
Do you consider yourself religious? (required)
YesNo
Comment?

Do you currently express this spirituality through religious practice? (required)
YesNo
Comment?

Would you like spirituality included in your counseling? (required)
YesNo
Church affiliation

Ethnicity
Caucasian/WhiteAmerican Indian/Alaska NativeMiddle EasternAfrican American/BlackNative Hawaiian/Pacific IslanderAsianHispanic/LatinoOther

Education of Adults in Household (check all that apply)
Some High SchoolAssociate’s DegreeDoctorateHigh School GraduateBachelor’s DegreeTrade/SpecialtySome CollegeMaster’s DegreeOther

very unhappyimpulsiveundependableself-controlinsecurityobsessive/compulsiveintense headachesstealingirritable/criticalnervousnesstemper outburstsbullyingno joypanic attacksemployment problemslonelinesswithdrawn/isolationracing thoughtsrepetitive/ritualistic behaviorsgrieftirednessfearfulseizureslyingfrustrationshynessfinancial stressflashbacksmoodyworrylegal problemsnightmaresdepressionhealth problemsproblems w/ex-spouseeating problemsmemory lossself-harmingsexual problemssleeping problemsshort attention spanstressed outrelationship issuesbed wettingconcentration difficultydestructiveaffairschool issuescrying spellsexcessive daydreamingdivorce/separationwork/career issueslack of energyhair pullingsignificant alcohol usepornography uselacks motivationmean to othersproblems with friendsdrug usedifficulty making decisionsdistractibleparenting problemssocial problemsemotional abuseparanoiastomach/bowel problemssexual abusestrange thoughtschronic painphysical abusestrange behaviorproblems w/parentshomicidal thoughtssuicidal thoughts

Explain

Goal 1

Goal 2

Goal 3

Is there anything else that you feel is important for your therapist to know?