Name (last, first, middle initial, maiden name(if applicable):
Date of Birth (month, date, year):
Mailing Address (street, city, state, zip code):
Whom may we contact in an emergency? (name, phone number, relationship):
May we leave a message for you?
Work Address (street, city, state, zip code)
Method of payment
InsurancePersonal payment(not insurance)
Primary Insurance Information
Health Insurance Carrier
Subscribers Phone Number
Subscriber’s Address (street, city, state, zip code)
Subscribe’s Date of Birth
Subscriber’s Social Security Number
Other Insurance Information
Family of Origin (Growing Up)Please list parents,
siblings, step-family members (name, relationship, age, health)
Current Living Situation Please list everyone in the home,
including pets(name, relationship, age, date of birth, gender)
Number of children
Why are you seeking counseling? (chief complaint)
When did this start, or when did you first notice the chief complaint?
Current illnesses or injuries
Please list current prescription medications (medication, dosage, frequency, purpose (e.g., Lipitor, 40mg, 1X/day, lowers cholesterol))
Please list any other non-prescription medications used within the last year on a regular basis
Do you smoke?
If yes, how many cigarettes per day?
Do you drink coffee or other caffeinated drinks?
Cups per day of caffeinated?
Cups per day of decaffeinated?
How often do you drink alcohol?
Never1-10 times per year1-3 times per month1-3 times per week4+ times per week
How often do you consume recreational drugs?
Seldom/Never1-3 times a month1-3 times per week1-3 times a day
High school completed?
Are you a veteran?
If yes, branch of service and dates
Who referred you to our practice?(Name, address, phone)
Recent physical changesWeight gainWeight lossConfusion and/or spacinessFamily conflictWork conflictSchool conflictForgetfulnessIntentional forgetfulnessUnintentional forgetfulnessMissing social cluesLow self-confidence or self-esteemLack of emotional controlSuperiorityInferiorityIsolation and/or lonelinessFrustration/irritation/angerAbandonmentCommunication problemsHearing problemsSpeaking problemsReading problemsWriting problemsrestlessnesssleep problemscan’t get to sleepcan’t stay asleepcan’t wake uphopelessnessovewhelmedanxiety or panichyperactivity or impulsivitymood swingsdestructive tendenciessuicidal threats/attemptshomicidal threats/attemptsfearfulnessspiritual/religious concernshelplessnessdepressionunattractivenesssexual issuesdisorganizationsome difficulty being on timeguilt or shameboredomobsessiveness and/or compulsivenessunwanted thoughts, voices, or imagescrisis or traumadissociation (lost time - “checking out”)unusual or inappropriate behavior
Could you describe any other symptoms you've had?
Have you had previous psychotherapy?
If yes, please give therapist’s names and dates
Are you currently involved in psychotherapy elsewhere?
If yes, contact information for therapist (Name, Address, City, Zip, Phone)
Past hospitalizations for psychiatric reasons (dates, and reason for admission)
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