Client Name:
Date of Birth:
Gender:
Preferred Pronouns:
Reason(s) for seeking treatment:
Briefly describe your therapy goals:
Name:
Age:
Relationship:
Occupation/School:
Name:
Age:
Relationship:
Occupation/School:
Name:
Age:
Relationship:
Occupation/School:
Name:
Age:
Relationship:
Occupation/School:
Message:
If Yes(Specify)
Yes(Specify):
Employer name:
How long have you worked there?
If Yes (branch):
If Yes(Specify):
Primary Care Provider:
Psychiatrist:
Medication:
Strength/Dosage:
Medication:
Strength/Dosage:
Medication:
Strength/Dosage:
Medication:
Strength/Dosage:
Medication:
Strength/Dosage:
Medication:
Strength/Dosage:
Allergen:
Reaction:
Allergen:
Reaction:
Allergen:
Reaction:
Allergen:
Reaction:
Allergen:
Reaction:
Allergen:
Reaction:
List any current or past medical conditions:
List any previous hospitalizations, surgeries, or major injuries, including dates:
List any family history of mental illness or substance abuse (ex: depression, alcoholism, etc):
If yes, please list provider, reason for treatment, and dates:
Yes (how much/how often):
Yes (type(s), how much/how often):
Have you received any previous mental health treatment?
Abuse history including physical, emotional, sexual and/or exposure to domestic violence, past and present:
Yes (specify):
Yes (specify):
Please add any further information you feel the therapist should know:
If you are interested in corresponding with your therapist by email concerning appointment scheduling ONLY, please provide your email address:
Client Name
DATE
