750 Old Main Street, Suite 306, Rocky Hill, CT 06067
(860) 342-0493
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Client and Family Information
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Client Information:
Client Name
Gender
Date of Birth
MM slash DD slash YYYY
Address
Street Address
City
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Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone (H)
Employer (Name & Address) / School
Occupation
Phone (W)
Family Information (family members living in the home):
Name / Relationship
Gender
Date of Birth
MM slash DD slash YYYY
Age
Employer (Name & Address) / School
Occupation
Phone (W)
Name / Relationship
Gender
Date of Birth
MM slash DD slash YYYY
Age
Employer (Name & Address) / School
Occupation
Phone (W)
Name / Relationship
Gender
Date of Birth
MM slash DD slash YYYY
Age
Employer (Name & Address) / School
Occupation
Phone (W)
Name / Relationship
Gender
Date of Birth
MM slash DD slash YYYY
Age
Employer (Name & Address) / School
Occupation
Phone (W)
Family Information (any immediate family members not living in the home):
Please list family members / relationships
Client's Medical Information:
Physician & Address
Phone
Medical Conditions (including allergies)
Medications & Dosages / Prescribing Physician
Hospitalizations / Dates / Reasons
Were any other counseling professionals consulted? / Dates / Reasons
Problem Checklist
Current symptoms and problems: This list is to help you identify issues that may contribute to your discomfort. Please rate the degree to which you experience the following symptoms or problems. If a particular problem does not apply to you then you may leave it blank. Please circle items that cause you particular concern.
1 - Mild. 2 - Moderate. 3 - Severe.
Behavior Problems:
Compulsive gambling
Compulsive eating
Compulsive shopping
Inappropriate sexual behavior
“Manic” behavior
Temper/aggression/violence toward others
Aggression toward self (cutting, mutilation, etc.)
Other:
Emotional Problems:
Anxiety
Depression
Excessive worries or fears
Excessive jealousy
Low self-esteem
Nightmares
Obsessive thoughts
Panic attacks
Self-critical
Suicide attempt (explain when and how below)
Suicidal thoughts or feelings
Thoughts or impulses to harm another person
Self-harm behaviors (i.e. cutting, pulling hair, etc.)
Marital / Family Problems:
Affair / infidelity
Child custody issues
Death or loss of family member/significant other
Divorce issues
Family violence
Financial problems
Marital / relationship problems
Problems with children or other family members
Other:
Life Transition Issues:
Identity issues
Major life changes
Mid-life crisis
Relationship break-up
Other:
Legal Problems:
Current legal difficulties
Past legal problems
Other:
Physical Problems:
Difficulty sleeping
Difficulty eating
Eating disorder
Pain
Sexual problems (performance)
Sexual problems (libido)
Somatic (physical) complaints
Other:
Social Problems:
Abandonment
Intimacy problems
Problems with social relationships
Work/occupational problems
Other:
Substance Abuse / Addiction:
Alcohol abuse
Alcoholism
Drug abuse
Drug addiction
Prescription drug abuse
Other:
Trauma:
Catastrophic trauma survivor
Childhood abuse survivor
Physical / sexual abuse survivor
Witness to violence
Other
Other: please describe any other issues
Eating Disorder:
Restricting: yes/no
Binge/purge: yes/no; how often:
Overeating: yes/no; how often
Exercise patterns:
Date of onset:
** Briefly explain the circled items
PRESENT MOTIVATION LEVEL FOR THERAPY (SCALE 1-5 - 5 IS HIGH MOTIVATION):
Name of individual completing this form:
Email
Date
MM slash DD slash YYYY
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