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New Cover Page
Home
Psychology Today profile
Intake Forms
Contact
About
Client Information
Consent to Treatment
Psyc Emp Serv Policies and Practices
HIPPA - Notice of Privacy Practices
Credit Card Acknowledgement form
This is a strictly confidential patient medical record. Re-disclosure or transfer is expressly prohibited by law.
Adult Client Information Form1:
NOTE: If you were a patient here before, please fill in only the information that has changed.
Today's Date
*
MM
DD
YYYY
A. Identification
Your legal name
*
First Name
Last Name
Date of Birth
*
MM
DD
YYYY
Other names you have used (maiden, nicknames, aliases):
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
*
(###)
###
####
Email Address
*
Drivers License number or
Other ID number
Disability Status or
Talk about disability status later
Religious / spiritual traditions or identities
Other ways you identify and consider yourself important
B. Emergency information:
If some kind of emergency arises and we cannot reach you, whom should we call?
Name
*
Phone
*
Relationship:
*
C. Referral
Who gave you my name to call?
Telephone
(###)
###
####
How did this person explain how I might be of help to you?
Is this person’s relationship with you
Personal
Professional
If professional, may I let this person know that you have come to see me?
Yes
No
D. Current problems or difficulties
Please describe the main difficulties that led to your coming to see me:
When did these problems start?
What makes these problems worse?
What makes these problems better?
With therapy, how long do you think it will take for these to get a lot better?
E. Your medical care
From whom, or where, do you get your medical care? Clinic/doctor’s name:
Clinic / Doctor's address:
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Clinic / Doctor's telephone number:
(###)
###
####
Results of your last physical exam:
If you enter treatment with me for psychological problems, may I tell your medical doctor so that he or she can be fully informed and we can coordinate your treatment?
Yes
No
Rate your general level of health:
Excellent
Good
Fair
Poor
Extremely poor
Current Medications:
For what condition(s)?
Prescribed and supervised by:
F. Your education and training
How many years of school have you had (including elementary and high school)?
Degrees/certificates:
Field(s) of study:
G. Employment and military experiences
Current occupation:
Current employer:
Employers address:
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
How much debt do you have?
$
H: Family History
Parent / guardian 1:
Name:
Current age (or age at death)
Illnesses? (or cause of death, if deceased)
Education:
Occupation:
Please describe this caregiver:
How did this person discipline you?
How did this person reward you?
How much time did this person spend with you when you were a child?
A lot
Average
Little
How did you get along with this person when you were a child?
Poorly
Average
Well
How do you get along with this person now?
Poorly
Average
Well
Does not apply
Did this person have any problems (e.g., alcoholism, violence) that may have affected your childhood development?
Yes
No
Don't know
Is or was there anything unusual about this relationship?
Yes
No
Parent / guardian 2:
Name:
Current age (or age at death)
Illnesses (or cause of death, if deceased)
Education
Occupation
Please describe this caregiver:
How did this person discipline you?
How did this person reward you?
How much time did this person spend with you when you were a child?
A lot
Average
Little
How did you get along with this person when you were a child?
Poorly
Average
Well
How do you get along with this person now?
Poorly
Average
Well
Does not apply
Did this person have any problems (e.g., alcoholism, violence) that may have affected your childhood development?
Yes
No
Don't know
Is or was there anything unusual about this relationship?
Yes
No
Stepparents
Name(s)
Current age (or age at death)
Illnesses (or cause of death, if deceased)
Education:
Occupation:
Other relationships:
I. Your significant non marital relationships (past and present)
J. Marital/couple relationship history
First spouse's / partner's name:
His / her age at marriage:
Your age at marriage:
Your age when divorced / widowed (if applicable):
Has he / she remarried?
Yes
No
n/a
Second spouse's / partner's name:
His/her age at marriage:
Your age at marriage:
Your age when divorced/widowed:
Has he/she remarried?
Yes
No
n/a
K. Children
L. Religious concerns
What role, if any, does faith or spirituality play in your life?
What is your present religious affiliation, if any?
M. Other
Is there anything else that is important for me to know about, and that you have not written about on any of these forms?
Yes
No
If yes, please explain
Religious / spiritual traditions or identities:
