Client Information Form Step 1 of 3 33% Name* Today's DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Address City State Zip PhoneWorkCellMay we leave a message ? Yes No Which number ? Phone Work Cell Emergency Contact DetailsName PhoneAddress City State Zip Personal InformationDate of BirthMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920AgeSexMaleFemaleMarital Status Where are you employed ? Position Are you in school ? Yes No Where Grade Any military sevices Yes No What branch Rank Have you ever been arrested ? Yes No If yes, explain Do you have a religious preference ? Do you exercise daily ? Yes No Type How frequent How would you rate your diet ? Poor Fair Excellent Any recent weight gain or loss ? Yes No How many pounds Do you consume caffeine ? Yes No How much Do you drink alcohol ? Yes No How much Have you or do you use illicit drug ? Yes No List all illicit drugs used past or current How do you sleep ? Poor Fair Well How may hours do you sleep per night How is your energy level ? High Average Low How is your interest in things you enjoy ? High Average Low Has this changed ? Yes No MEDICAL HISTORYDate of Last Physical Exam Primary Care Physician Primary Care Physician’s practice name and address Please list any medical issuesDo you have any current physical distress such as headaches, backaches, stomachaches, etc Yes No If yes, please explain Any surgeries Yes No If yes, please list type and date Have you been involved in any accidents requiring medical attention Yes No If yes, please explain Please List all current medications and prescribing physiciansCurrent MedicationsDosage Amount/FrequencyPrescribing MD PERSONAL HISTORYHave you ever seen a counselor or a psychiatrist Yes No If yes, please provide name, dates, and reasons you sought help Have you ever been abused Mentally Physically If yes, Please explain What is your mother’s name AgeStill living Yes No What was/is her occupation Do you have a good relationship Yes No Any history of mental health issues such as depression, anxiety, etc What is your father’s name AgeStill living Yes No What was/is his occupation Do you have a good relationship Yes No Any history of mental health issues such as depression, anxiety, etc Are you in a relationship currently Yes No With whom Any recent deaths of anyone significant in your life Yes No If yes, explain Please list you hobbies or activities you do for fun What is the highest level of education completed Where Did you graduate Yes No Where How were/are your grades Excellent Average Poor Do you have difficulty with focus and attention Yes No Do you follow directions Yes No Has anyone ever told you you are hyperactive or impulsive Yes No Were you ever bullied in school Yes No Did you bully anyone in school Yes No Are you currently suicidal or homicidal Yes No if yes, please explain EmailThis field is for validation purposes and should be left unchanged.
