Client Information

Client Name*

First Last

Client Date of Birth

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Preferred method of communication

Phone
Email
Text

Home Phone

Message

Ok to leave message?

Mobile Phone

Mobile

Ok to leave message?
Ok to text?

Email

Insurance Information

Primary Insurance

ID #

Group #

Policy Holder Name

First Last

Policyholder Date of Birth

Client Relationship to Policyholder

Hidden

Responsible party name

If client is a minor

Background Information

Reason for seeking help at this time.

Previous or current counseling

Name of Counselor or Agency

Year

Approximate Number of Sessions

Name of Counselor or Agency 2

Year 2

Approximate Number of Sessions 2

Name of Counselor or Agency 3

Year 3

Approximate Number of Sessions 3

Current 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:

Other

Is there anything else that would be helpful for me to know about you prior to beginning counseling?

Requested Therapist(s)*

Jill Ellingson
Ingrid Tucci
Rebekah Morse
Jamie Dahlberg
Nikki DiVirgilio
Amanda Redepenning
Kristen Brechler
Michael Smith
Any Available Therapist

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