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New Client Information
New Client Information
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Name
*
First
Last
Email
*
Email
Confirm Email
Birthday
*
Addresss
*
City, State, ZIP
*
Home Phone
Work Phone
Cell Phone
*
Other Phone
Referred by
Relationship Status
Emergency Contact
*
First
Last
Emergency Contact Cell Phone
*
Emergency Contact Home Phone
Name of Your Physician
Physician's Phone
Insurance Company
What do you hope to accomplish in therapy?
Current Symptom Checklist, check all that apply, even minor symptoms
Depressed mood
Racing thoughts
Excessive worry
Unable to enjoy activities
Impulsivity Anxiety
Sleep pattern disturbance
Increase risky behavior
Avoidance
Loss of interest
Increased libido
Hallucinations
Concentration/forgetfulness
Decrease need for sleep
Suspiciousness
Change in appetite
Excessive energy
Decreased libido
Excessive guilt
Increased irritability
Suicidal thoughts
Fatigue
Crying spells
Select all that apply
Other Symptoms
Major Symptom Checklist
Depressed mood
Racing thoughts
Excessive worry
Unable to enjoy activities
Impulsivity Anxiety
Sleep pattern disturbance
Increase risky behavior
Avoidance
Loss of interest
Increased libido
Hallucinations
Concentration/forgetfulness
Decrease need for sleep
Suspiciousness
Change in appetite
Excessive energy
Decreased libido
Excessive guilt
Increased irritability
Suicidal thoughts
Fatigue
Crying spells
Select all that apply
Other Major Symptoms
Alergies
Please place a check mark next to medical issues you have ever experienced
Thyroid Disease
Anemia
Liver Disease
Chronic Fatigue
Kidney Disease
Diabetes
Asthma/respiratory problems
Stomach/Intestinal
Cancer
Fibromyalgia
Heart Disease
Epilepsy or seizures
Chronic Pain
High Cholesterol
High blood pressure
Head Trauma
Liver problems
Current Medical issues
Other past medical problems, nonpsychiatric hospitalization, or surgeries:
Do you have any concerns about your physical health that you would like to discuss?
Yes
No
Psychiatric History: Outpatient Treatment
Yes
No
Outpatient Treatment: If yes, please provide any information that would be helpful for your current therapy
Family Psychiatric History. Has anyone in your family been diagnosed with or treated for:
Bipolar disorder
Schizophrenia
Depression
Post-traumatic stress
Anxiety
Alcohol abuse
Anger
Suicide
Violence
Substance abuse
Please list substances used on a regular basis
Family History: Were you adopted?
Yes
No
Where did you grow up?
Please list your siblings and their ages
Who were/are your primary caregivers?
If your parents divorced, with whom did/do you live?
Mother
Father
Not Divorced
Please briefly describe your relationship each of your immediate family members
Highest Grade Completed?
None
1
2
3
4
5
6
7
8
9
10
11
12
1 Year College
2 Years College
3 Years College
4 Years College
Graduate School
Post Graduate
Favorite Subjects
College Name and Major
What did/do you think of school?
Love(d)
It Like(d) It
Meh
Did/Do Not Like It
Hate(d) It
Not My Thing
Are you currently:
Working
Student
Unemployed
Disabled
Retired
How many years at your current position?
What is/was your occupation?
Where do/did you work?
Have you ever served in the military?
Yes
No
Relationship status
Single
Dating
Married
Partnered
Divorced
Widowed
How many years?
Use a decimal if < 1 year
Who do you live with?
List your children and their ages and gender, 1 per line
Please describe your relationship with your children...
Physical Health : Do you exercise regularly?
Yes
No
How many days a week do you exercise on average
1
2
3
4
5
6
7
How many hours a day do you exercise on average?
What kinds of exercise are you doing?
Is there anything else that would be helpful for me to know?
Name
Submit
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