Client Information
Identification
Name:_______________________________________________________________________________
Preferred Nickname: ____________________________Social Security #: ________________________
Insurance Provider: _____________________________ Identification #: _________________________
Date of Birth: ______________ Age: _________ Gender: M _____ F _____
Phone #s where I may call you: _____________________ May I leave a message: Yes _____ No _____
_____________________ May I leave a message: Yes _____ No _____
Email address where I may contact you: ____________________________________________________
Local stress address: _________________________________________________ Apt.: ______________
City: _______________________________ State: ______________ Zip: ________________
Permanent home address: ____________________________________________ Apt.: ______________
City: _______________________________ State: ______________ Zip: ________________
Presenting Concerns and Psychiatric History
Please describe the main concern that brought you to see me and any goals you have for therapy: _____
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When did these problems begin? __________________________________________________________
Other concerns or issues? _______________________________________________________________
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Have you ever received psychological counseling or psychiatric services? No _____ Yes _____
If yes, please indicate:
When? From whom? For what? With what results?
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Any previous hospitalizations or ER visits for emotional or psychiatric reasons? No _____ Yes _____
If yes, please indicate:
When? From whom? For what? With what results?
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Are you currently taking any psychiatric medications? No _____ Yes _____
If yes, please describe:
Name of medication: ___________________________________________________________________
Now long? ____________________________________________________________________________
Who prescribes? _______________________________________________________________________
Have you ever attempted to harm or kill yourself? No _____ Yes _____
Are you currently having thoughts of harming or killing yourself? No _____ Yes _____
Are you currently having thoughts of harming or killing someone else? No _____ Yes _____
Have you ever injured yourself intentionally? No _____ Yes _____
Who is your primary care physician? _______________________________________________________
Date of last visit: ________________________________