Client Name
Address Phone Email Primary Physician Phone Current Therapist Phone
What is your major complaint? Start Date: Have you previously suffered from this complaint? Yes No Previous therpist(s) seen for complaint: Previous treatment for complaint: Aggravating Factors: Relieving Factors:
Anxiety Depression Hallucinations Loss of Interest Sleep Changes Appetite issues Excessive Energy Impulsivity Panic Attacks Suspiciousness Avoidance Fatigue Irritability Racing Thoughts Crying Spells Guilt Libido Changes Risky Activity
Exercise Frequency: Exercise Types(s): Allergies: What medications are you currently using? Previous diagnoses/mental health treatment: Previously treated by: Previous Medications: Dates Treated: Previous Medical Conditions: Previous Surgeries:
Were you adopted? Yes No If yes, at what age? How is your relationship with your mother? How is your relationship with your father? Siblings and their ages: Are your parents married? Yes No Did your parents divorce? Yes No If yes, how old were you? Did your parents remarry? Yes No If yes, how old were you? Who raised you? Where did you grown up? Family member medical conditions: Family member mental conditions: Treated with medication? Medications:
Where did you grow up? How often did you move and where? How old were you when you left home? Have any immediate family members died? Yes No If so, who? Have any committed suicide? Yes No If so , Who? Describe any neglect you suffered, and by whom: Trauma suffered and by whom: Abuse suffered and by whom: Highest education level completed: Date completed and location: Have you ever served in the military? Yes No If yes, where? Dates of service: Highest rank achieved:
Full-Time Part-Time Student Unemployed Disabled Retired Are you married? Yes No If yes, date of marriage: Are you divorced? Yes No If yes, date of divorce: Prior marriages? Yes No If yes, how many? What is your sexual orientation? Are you sexually active? Yes No How is your relationship with your partner? Do you have children? Yes No Dates of Birth: How is your relationship with your child(ren)? List anyone else who lives with you: Are you a member of a religion/spiritual group? What is your level of involvement? Have you ever been arrested? Yes No When and why?
Alcohol Heroin Ecstasy Tobacco Methamphetamines Methadone Marijuana Cocaine Tranquilizers Hallucinogens (LSD) Stimulants (Pills) Pain Killers If yes to any, list frequency/dates of use: Have you ever been treated for drug/alcohol abuse? Yes No If yes, when? For which substances? Do you smoke cigarettes? Yes No If yes, how many per day? Do you drink caffeinated beverages? Yes No If yes, how many per day? Have you ever abused prescription drugs? Yes No If yes, which ones?
Client Signature: Date:
**All fields must be completed in order to successfully submit this form
