CLIENT INFORMATION QUESTIONNAIRE
Date _________________
Name _____________________________ Date of Birth _____________ SSN ______________
Address ______________________________________________________________________
Street City & State Zip Phone: Home _________________ Work___________________ Cell _______________
E-mail address: _________________________________________________________________
May I call/leave a message at home? _____ At work? _____ Cell phone? _____ E-mail?______
Occupation __________________________
Employer name & address ___________________ _________________________________________________________________________
Estimated gross annual household income: ___________________________________________
Education (last grade completed) _______ Current relationship status _____________________
Local emergency contact person ______________________________________
Relationship to you _________________ Home phone ____________________ Work phone _____________
Please describe the issues or concerns which you would like to address in therapy at this time: _______________________________________________________________________________________
_______________________________________________________________________________________
Have you been in therapy before? ________
If yes, please state when and where : ___________ __________________________________________________________________________
Are you in counseling/therapy now?______ If so, with whom? ___________________________
Please describe any illness, loss, accident, or hospitalization that had a big impact on your life,
and give the dates of their occurrences: ________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Do you have any major health concerns? _____________________________________________ __________________________________
________________________________________________________________________________________
Please list any medication(s) you are currently taking and the dosage ______________________ ___________
________________________________________________________________________________________
Have you ever taken a psychiatric medication (e.g., for depression, anxiety)? ________________
Primary physician _________________________________ Phone________________________
Physician's address ______________________________________________________________
Have you ever been physically or emotionally abused, either as a child or as an adult?
Yes ________ No ________ Uncertain ________
Have you ever had an unwanted sexual experience, either as a child or as an adult?
Yes ________ No ________ Uncertain ________
Have you ever had a psychiatric hospitalization? ______ If so, when ______________________
Have you ever attempted suicide? __________________________________________________
Have you or any member of your immediate family (or household) ever had any alcohol or
substance-abuse related problems? Yes ____ No____ If yes, please explain: ________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Use other drugs? ______________________________________________________________________________
Please provide the following information about your immediate family members (partner/spouse, children, parents,
siblings, step-parents)
Name Relationship Age or Age of Death City of Residence
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Name of person who referred you _______________________________
May I acknowledge the referral? ________________________________
Below is a list of concerns people often have. Please indicate the degree to which each one is a concern for you.
| 0 = not at all 1 = a little 2 = moderately 3 = quite a bit 4 = very much |
| Alcohol or drug use |
0 1 2 3 4 |
Appearance/weight |
0 1 2 3 4 |
| Assertiveness |
0 1 2 3 4 |
Expressing feelings |
0 1 2 3 4 |
| Irritability |
0 1 2 3 4 |
Financial matters |
0 1 2 3 4 |
| Grief |
0 1 2 3 4 |
Nervousness |
0 1 2 3 4 |
| Meeting people |
0 1 2 3 4 |
Loneliness |
0 1 2 3 4 |
| Energy level |
0 1 2 3 4 |
Mood swings |
0 1 2 3 4 |
| Temper |
0 1 2 3 4 |
Depression |
0 1 2 3 4 |
| Sexual problems |
0 1 2 3 4 |
Sexual orientation |
0 1 2 3 4 |
| Insomnia |
0 1 2 3 4 |
Insecurity |
0 1 2 3 4 |
| Anxiety |
0 1 2 3 4 |
Racing thoughts |
0 1 2 3 4 |
| Making decisions |
0 1 2 3 4 |
Low self esteem |
0 1 2 3 4 |
| Excessive worry |
0 1 2 3 4 |
Parenting concerns |
0 1 2 3 4 |
| Urge to harm self |
0 1 2 3 4 |
Urge to harm other |
0 1 2 3 4 |
| Overeating |
0 1 2 3 4 |
Loss of appetite |
0 1 2 3 4 |
| Fears |
0 1 2 3 4 |
Suicidal thoughts |
0 1 2 3 4 |
| Poor concentration |
0 1 2 3 4 |
Motivation |
0 1 2 3 4 |
| Procrastination |
0 1 2 3 4 |
Lack of friends |
0 1 2 3 4 |
| Time management |
0 1 2 3 4 |
Too passive |
0 1 2 3 4 |
| Impulse control |
0 1 2 3 4 |
Memory lapses |
0 1 2 3 4 |
| Feelings of unreality |
0 1 2 3 4 |
Lack of trust |
0 1 2 3 4 |
| Feelings of worthlessness |
0 1 2 3 4 |
Guilt |
0 1 2 3 4 |
| Health |
0 1 2 3 4 |
Shyness |
0 1 2 3 4 |
| Aggressiveness |
0 1 2 3 4 |
Anger |
0 1 2 3 4 |
| Loss of time |
0 1 2 3 4 |
Work/career concerns |
0 1 2 3 4 |
| Handling stress |
0 1 2 3 4 |
Feeling overwhelmed |
0 1 2 3 4 |
| Spiritual concerns |
0 1 2 3 4 |
Tension |
0 1 2 3 4 |
| Relationships: |
| Significant other |
0 1 2 3 4 |
Friends |
0 1 2 3 4 |
| Family |
0 1 2 3 4 |
Other_______________ |
0 1 2 3 4 |
Employer |
0 1 2 3 4 |
|
|
Is there any other information which you feel may be useful to your treatment? _________________
____________________________________________________________________________
Who is financially responsible for your treatment?
Name ___________________________________________ Relationship to you _____________
If you will be using insurance coverage, please have your insurance card available.
Thank you for completing this questionnaire.
_______________________________________________________________________________________
FOR OFFICE USE ONLY__________________________________________________________________
Date __________________ Number called ______________________ Spoke to _____________________
Effective date ________________ Deductible: $________________ Amount met $___________________
Limits: No. of visits _________ or amount limit___________ Annual ___________ Lifetime ____________
Reimbursement rate: _____________________________________________________________________
_______________________________________________________________________________________
Special instructions (e.g., OTR's, call for authorization of additional visits, etc.) ________________________
_________________________________________________________________________________________
