Client Information Form – New Foundation

Name

Address

City

State

Zip

Phone Nmmber

Email Address

What is the best way to contact you?

May I leave a detailed message at this number or email?

Gender

Date Of Birth

Age

Relationship Status

Ethnic Origin

Occupation

Emergency contact

Does emergency contact person know you are in counseling?

Referred by

Prior experience with therapy

Yes No

If yes, with whom? concerns discussed? and for how long (please include dates)?

Have you ever been hospitalized for a psychiatric condition?

Yes No

If yes, for what condition? Where? and for how long (please include dates)?

Are you currently taking any medications? Please list all medications you are taking and when you started?

Please check all that apply to you

I have felt like or tried harming

Major medical problems or disabilities

Have you had any serious illness or injuries?

If yes, what?

The following have resulted from my drinking and/or use of drugs:

Please list all medications you are taking:

What are you seeking treatment for at this time?

Family Information