NEW CLIENT INFORMATION FORM
Your responses to the following questions will help your psychologist better understand you and your situation.
This will facilitate the best possible treatment. Please answer all questions as completely as possible.
CLIENT INFORMATION
Name:
Email address:
Address:
City/State/Zip:
Home:
Age:
Work:
Marital Status:
Single ☐ Married/Partnered ☐
Male ☐
Female☐
Cell:
Separated ☐ Divorced ☐ Widowed ☐
PRESENTING PROBLEM
Please describe, in your own words, what brings you to therapy?
When did these problem(s) begin?
How has it changed over time?
How have you attempted to cope with this problem or concern?
Please check if you are experiencing any of the following problems:
☐ Anger
☐ Anxiety/Worry
☐ Body image concerns
☐ Depression
☐ Divorce
☐ Eating/Appetite
☐ Employment
☐ Family Concerns
☐ Financial
☐ Ill Health
☐ Interpersonal Concerns
☐ Marital/Relationship
☐ Pain
☐ Sexual
☐ Sleep /Insomnia
☐ Stress Management
☐ Substance Use/Abuse
☐Other:
PSYCHOLOGICAL HISTORY
Are you now or have you ever been diagnosed and/or treated for a psychological disorder?
☐ Yes (describe below)
☐ No
Have you ever taken medication for anxiety, depression, sleep or other emotional concerns?
☐ Yes (describe below)
Medication
☐ No
Condition
Prescriber
Approx. Start date/End date
MM/YY to
MM/YY to
MM/YY to
MM/YY to
MM/YY to
Have you ever been hospitalized for psychiatric reasons? ☐Yes ☐No
If yes, please specify:
Have you ever had suicidal thoughts? ☐Yes ☐No If yes, how often?
☐ Daily
☐ Weekly
☐ Monthly
☐ Rarely
Have you had suicidal thoughts recently? ☐Yes ☐No If yes, how often?
☐ Daily
☐ Weekly
☐ Monthly
☐ Rarely
Have you ever intentionally inflicted harm on yourself? ☐Yes ☐No If yes, how often?
☐ Daily
☐ Weekly
☐ Monthly
☐ Rarely
Have you ever intentionally inflicted harm on someone else? ☐Yes ☐No If yes, how often?
☐ Daily
☐ Weekly
☐ Monthly
☐ Rarely
Have you experienced abuse? ☐Yes
☐ Neglect
☐ Emotional
☐No ☐ Unsure
☐ Physical
If yes, what was its nature? (Check all that apply):
☐ Sexual
Have you experienced sexual assault, unwanted sex or uncomfortable touching?
☐ Frequently
☐ A few times
☐ Once
☐ Never
☐ Unsure
GENERAL MEDICAL HISTORY
How would you describe your physical health at present?
☐ Poor
☐ Fair
☐ Satisfactory
☐ Good
☐ Excellent
Please list any persistent physical symptoms or health concerns (e.g., chronic pain, headaches, diabetes, etc.):
Please list any prescribed medications you are presently taking:
Medication
Approx. Start
date/End date
MM/YY to
MM/YY to
MM/YY to
MM/YY to
MM/YY to
MM/YY to
MM/YY to
MM/YY to
Dose
XX mg
X times/day
XX mg
X times/day
XX mg
X times/day
XX mg
X times/day
XX mg
X times/day
XX mg
X times/day
XX mg
X times/day
XX mg
X times/day
Prescribing Physician
Comments
Who is your Primary Care Physician?
Name: Dr. or NP Name
Address:
1234 YOUR STREET
YOUR CITY, STATE,
XXXXX
Phone:
1.
XXX-XXXX
Are you having any problems with your sleep habits? ☐Yes ☐No For how long?
If yes, check where applicable:
☐ sleeping too little
☐ waking throughout the night
☐ sleeping too much
☐ disturbing dreams
☐ poor quality sleep
☐ other:
Are you having any problems with your memory? ☐Yes ☐No
How many times per week do you exercise?
For how long?
For how long?
Are you having any difficulty with appetite or eating habits? ☐Yes ☐No For how long?
If yes, check where applicable:
☐ eating less
☐ restricting calories
☐ other:
☐ eating more
☐ weight change (past 2 months)
Are you having any problems with sexual functioning? ☐Yes ☐No
If yes, check where applicable:
☐ performance problem
☐ worry about STD(s)
For how long?
☐ sexual impulsiveness
☐ difficulty maintaining arousal
Do you regularly smoke cigarettes? ☐Yes ☐No
☐ binge eating
☐ purging
☐ lack of desire
☐ other:
For how long?
Do you regularly use alcohol? ☐Yes ☐No
In a typical month, how often do you have 4 or more drinks in a 24 hours period?
Have you ever tried to cut down on the amount of alcohol you consume? ☐Yes ☐No
Has anyone close to you ever been annoyed by your drinking? ☐Yes ☐No ☐Unsure
Do you consider your alcohol use a problem? ☐Yes ☐No ☐Unsure
How often do you engage in recreational drug use?
☐ Daily
☐ Weekly
☐ Monthly
Do you consider your drug use a problem? ☐Yes ☐No
☐ Rarely
☐Unsure
☐ Never
FAMILY & RELATIONSHIP HISTORY
Please list the most significant relationships throughout your life (including but not limited to parents, siblings,
spouse/partner, children):
Name
Relationship
Age
School/Occupation
City of Residence
CHILDHOOD RELATIONSHIPS
Who raised you? Mark all that apply:
☐ Both parents ☐Mother alone ☐ Mother
w/partner
☐Father alone
☐Father
w/partner
☐Other:
What is your parent’s marital status? Mark all that apply:
☐ Never married
☐ Married
☐ Divorced
☐One Remarried
☐ Both Remarried
In general, how happy or adjusted were you growing up?
☐Not at all
☐ Very little
☐ Average
☐Mostly
☐ Completely
How much is your childhood family a source of emotional support for you now?
☐Not at all
☐ Very little
☐ Average
☐ Substantial
☐ Always
How much conflict did you experience in your childhood family growing up?
☐Not at all
☐ Very little
☐ Average
☐ Substantial
☐ Always
How much conflict do you experience in with your childhood family now?
☐Not at all
☐ Very little
☐ Average
☐ Substantial
☐ Always
Who in your childhood family do you feel closest to
Most distant from?
In most conflict with?
CURRENT RELATIONSHIPS
Who currently lives in your household?
In general, how happy or satisfied are you with your household relationships?
☐Not at all
☐ Very little
☐ Average
☐Mostly
☐ Completely
How much are your household relationships a source of emotional support for you?
☐Not at all
☐ Very little
☐ Average
☐ Substantial
☐ Always
How much conflict do you experience in your household relationships?
☐Not at all
☐ Very little
☐ Average
☐ Substantial
☐ Always
Who in your household do you feel closest to?
Most distant from?
In most conflict with?
RELATIONSHIP CONCERNS
Please check any past, present or impending problems/issues within your family:
Problem
Anxiety/Panic Disorder
Self
☐
Other
☐
Problem
Eating Disorder
Self
☐
Other
☐
Alcohol/Drug Abuse
☐
☐
Financial Crisis/Unemployment
☐
☐
Chronic or Serious illness
☐
☐
Legal problems
☐
☐
Deaths
☐
☐
Marital affairs/infidelity
☐
☐
Depression/Bipolar Disorder
☐
☐
Physical/Sexual Abuse
☐
☐
Disability/Debilitating Injury
☐
☐
Suicide (attempted or completed)
☐
☐
Divorce
☐
☐
Other
☐
☐
EDUCATION AND VOCATIONAL HISTORY
Please indicate your highest level of education:
☐ Less than high school
☐ HS equivalent/GED
☐ Some college
☐ Bachelor’s degree
☐ High school diploma
☐ Master’s degree
☐ Vocational
☐ Doctoral degree
What was your major/minor/are of concentration?
Did you any experience learning problems in school?
☐Not at all
☐ Very little
☐ Average
☐ Substantial
☐ Always
Overall, how satisfied are you with your academic progress so far?
☐Not at all
☐ Dissatisfied
☐ Satisfied
☐Very Satisfied
☐ Completely
Describe any obstacles that are impeding your academic progress.
Are you employed? ☐Yes ☐No
If yes, what is your current job and/or occupation?
If no, for how long has you been out of the work force?
Overall, how satisfied are you with your current employment situation?
☐Not at all
☐ Dissatisfied
☐ Satisfied
☐Very Satisfied
Have you ever been fired from a job?
Have you ever walked off a job?
☐ Yes (describe below)
☐ Yes (describe below)
☐ Completely
☐ No
☐ No
MILITARY SERVICE
Have you ever served in the military? ☐Yes ☐No If yes, please indicate:
Branch
Dates of Service
MM/YY to
MM/YY to
MM/YY to
Type of Discharge
Do you have a combat history? ☐Yes ☐No
Overall, how satisfied are you with your experience of military service?
☐Not at all
☐ Dissatisfied
☐ Satisfied
☐Very Satisfied
LEGAL HISTORY
Do you have a legal history consisting of past or current (Check all that apply):
Explain:
☐ Arrest(s)
Explain:
☐ Divorce/Custody
Explain:
☐ Incarceration(s)
Explain:
☐ Lawsuit(s)
Explain:
☐ Probation
☐ Restraining Order(s) Explain:
Explain:
☐ Other:
☐ Completely
THERAPEUTIC GOALS & OUTLOOK
What goals would you like to accomplish through treatment?
2.
1.
3.
2.
4.
3.
Overall, how does the future look to you?
☐Poor
☐ Fair
☐ Neutral
☐Good
☐ Excellent
Is there anything else you would like us to know about you?
YOU DID IT! Thank you for your time and effort.
This document has been reviewed by:
Provider Name (print):
Provider Signature:
Date: