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General Information
First Name
Last Name
Birthdate
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2023
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Gender
Male
Female
I'd rather not say
Marital Status
Single
Married
Widowed
Separated
Divorced
I'd rather not say
Sexual Orientation (optional)
Heterosexual
LGBTQ+
Prefer Not To Say
Preferred Pronouns
He/Him
She/Her
Them/They
Other
Race/Ethnicity
Religion/Spirituality (if any)
Would you like faith based counseling?
Yes
No
Open To It
Contact Information
Address
Apartment, suite, etc.
City
State
Zip/Postal Code
Email
Phone Number
Preferred Contact Method
Call
Text
Email
Emergency Contact Information
Primary Emergency Contact
First Name
Last Name
Relationship
Phone Number
Secondary Emergency Contact
First Name
Last Name
Relationship
Phone Number
Local Emergency Numbers
Police
Fire Department
Crisis Hotline
Availability and Preferences
Preferred Days for Counseling
Monday
Tuesday
Wednesday
Thursday
Friday
Preferred Time of Day
Morning (8AM-12PM)
Afternoon (12PM-4PM)
Evening (4PM-8PM)
Family and Social History
Family Background
Who Raised You? (check all that apply)
Biological Parents
Single Parents
Grandparents
Foster Care
Adopted
Other
Briefly describe your relationship with your family of origin
Are there any family dynamics or significant events that have impacted your life?
Current Nuclear Family
Social Life & Relationships
How do you generally feel about your social relationships?
I make friends easily
I struggle to form relationships
I have a few close friends, but would like more
I feel socially isolated
Other:
Do you feel comfortable expressing your emotions to others?
Yes
No
Have you experienced any major losses? (death, breakup, estrangement)
Yes
No
If Yes, please describe
Presenting Problems and Mental Health
What brings you to counseling?
Anxiety
Depression
Stress
Relationship Issues
Grief/Loss
Trauma/PTSD
Self Esteem
Anger
Career/Work Issues
Family Conflict
Parenting Issues
Addiction
Other:
Coping Difficulties (check all that apply)
Difficulty Sleeping
Overeating/Under-eating
Social Withdraw
Panic Attacks
Difficulty Concentrating
Self Harm
Suicidal Thoughts
Substance Abuse
Mood Swings
Other:
Medical and Mental Health History
Medical History
Heart Disease
Diabetes
High Blood Pressure
Thyroid Issues
Chronic Pain
Neurological Disorders
Autoimmune Disorders
Other:
Drug Allergies
Current Medications
Have you been hospitalized for a medical or psychiatric condition?
Yes
No
If yes, please describe
Mental Health History
Have you previously attended therapy?
Yes
No
If yes, when and what for?
Has any family member been treated for:
Bipolar Disorder
Major Depression
Schizophrenia
Substance Abuse
If yes, who?
Lifestyle and Habits
Substance Use
Do you drink alcohol?
Yes
No
If yes, how often?
Do you smoke or vape?
Yes
No
If yes, how often?
Do you use recreational drugs?
Yes
No
If yes, which ones?
Daily Habits & Well-Being
About how many hours of sleep do you get per night?
Do you engage in physical activity?
Yes
No
How would you describe your diet?
Healthy/Balanced
Fast Food often
Special Diet? (keto, vegan, gluten free, etc)
If special, what kind?
Legal and Stress History
Have you had any legal issues?
Yes
No
If yes, please describe
What are your biggest sources of stress?
Work
Family
Relationships
Finances
Health
Other:
Self- Assessment ( 😔1 -10😁)
Overall Well-Being
Work/School Performance
Relationship/Social Life
Emotional Stability
Goals For Therapy
What do you hope to gain from counseling? (check all that apply)
Reduce Stress/Anxiety
Improve Self-esteem
Strengthen Relationships
Manage Depression
Learn Coping Strategies
Heal from Trauma
Other:
Who referred you to this practice?
Doctor
Friend/Family
Employer
Self
Online Search
Other:
Additional Notes
Client Signature
Date Input
Month
January
February
March
April
May
June
July
August
September
October
November
December
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1961
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1965
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1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
Year
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
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2000
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2045
If under 18 - Guardian Signature
Guardian Name
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