Client InformationClient Name* First Last Client Date of Birth MM slash DD slash YYYY Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Preferred method of communication Phone Email Text Home PhoneMessage Ok to leave message? Mobile PhoneMobile Ok to leave message? Ok to text? Email Insurance InformationPrimary InsuranceID #Group #Policy Holder Name First Last Policyholder Date of Birth MM slash DD slash YYYY Client Relationship to PolicyholderThis field is hidden when viewing the formResponsible party nameIf client is a minorBackground InformationReason for seeking help at this time.Previous or current counselingName of Counselor or AgencyYearApproximate Number of SessionsName of Counselor or Agency 2Year 2Approximate Number of Sessions 2Name of Counselor or Agency 3Year 3Approximate Number of Sessions 3Current school and/or employment. Do you like it?Marriages/Relationships/Friendships. How are they going currently?Names and ages of children and any information about them that may be helpful.Are you currently under medical care?If yes, explain/describe.What medications have you used in the past six months? Include any herbal medications or supplements.Please list frequency and dosage information.Any concerns with substance abuse, including alcohol?If yes, please explain.How significant a role does religion/spirituality play in your life?Family history of mental health issues.Check any of the following struggles that apply to you: Anxiety Panic attacks Sexual problems Headaches Financial problems Self control Work stress Chronic pain Memory Inability to cry Crying spells Depression Suicidal thoughts Drug/Alcohol use Unhappiness Health problems Legal problems Grief Fears/Phobias Guilt Anger Separation/Divorce Career Choices Religious matters Cutting/Self-mutilation Poor self-image Loneliness Eating disorders Difficulty concentrating Irritability/Impatience Relationships Thought patterns Rage Hitting people or things Insomnia/Troubled sleep Other OtherIs there anything else that would be helpful for me to know about you prior to beginning counseling?Requested Therapist(s)* Jill Ellingson Ingrid Tucci Jamie Dahlberg Nikki DiVirgilio Amanda Redepenning Kristen Brechler Michael Smith Izzy Barr Debi Larson | Certified Professional & Relationship Coach Sarah Gavin Anastazia Acker Lianna Cotant Pam Sutton Any Available Therapist CAPTCHA
