CONFIDENTIAL CLIENT INTAKE INFORMATION QUESTIONNAIRE

Name:

SSN:

Referred By:

Date of Birth:       Age:

Gender:

Male Female

Religion:

What Ethnic group do you identify with:

What is your --

Address:

City:

State: AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY       ZIP:

Email:

Telephone:

Home:

Work:

Cell:

Payment Information:

I accept cash, checks, and credit card payments. Payments are to be made prior to the start of each session. For credit card payments, please fill out the following information:

Credit Card No:

CVV: Exp:

Name:

(as it appears on card):

Occupation:

Employer Name & Address:

Name:

Address:

City:

State: AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY       ZIP:

Highest level of education completed:

Are you in school now?

YES NO

If YES, what school and what is your area of study?

Are you married or in a committed emotional relationship now (if applicable)? YES NO

If Yes, how long?

Partner's Name:

Partner's

Occupation:

Number and duration of previous marriages or partnerships.

You:

Your Partner:

Please list the name, age and gender of each person living in the home:

• NAME
• AGE
• GENDER

What prompted you to seek counseling at this time?

How long have you been concerned about this issue or problem? (When/How did it start?)

Who is involved/affected by the problem? Describe their involvment.

What have you already done to try to solve the problem? What has helped (even if only a little) and what has failed to help?

If the problem were solved, how would your life be different?

What are your goals for therapy?

HEALTH HISTORY INFORMATION

What is the name, address and phone number of your physician?

Name:

Address:

City:

State: AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY       ZIP:

Telephone:

Have you been under a physician's care for any reason in the last 5 years? If yes, please explain.

Have you ever been hospitalized? Yes No

If yes, please list the date of each hospital stay and the reason for the stay.

List any medication you are taking now and the purpose for taking them.

Have you (or your child/teen/family) been involved in therapy or any type of counseling programs?

Yes No

If yes:

When?

Where?

Reason for and length of counseling

How was therapy helpful or not helpful?

Is there anything else you think would be helpful for me to know about you or your situation?

No information about you is released to anyone without your written consent, except as required by law or court order. I am required by law to report suspected child abuse, elder abuse, and clear, concrete evidence of planned acts of violence towards oneself or others.

Client Signature

Date  

Parent/Guardian Signature (if needed)

Date