Date: _______________________

Section I (Client Information):

NAME _____________________________________________________________________

Last First Middle

ADDRESS __________________________________________________________________

Street City State Zip

PHONE (_____)________________(______)_________________(______)_____________

Home Work Cell or Other Phone

EMAIL ADDRESS ________________ SOCIAL SECURITY NUMBER ____________________

EMPLOYER ______________________________ JOB TITLE _______________________

DEMOGRAPHICS _____________________________________________________________

Birthdate |Age |Years of | Marital Status |length of current

Education(Sng;Mrd;Sep;Div;Wid)relationship

_____________________________________________________________

List Ages & Gender of Children

REFERRAL SOURCE __________________________________________________________

EMERGENCY CONTACT _______________________Relationship:__________________

ADDRESS _______________________________________________________________

Street City State Zip

PHONE (_____)_________________(_____)______________(_____)___________________

Home Work Cell

Section II (Insurance Information)

Primary Insurance:

NAME OF INSURED _________________________ Relationship ________________

(Spouse;parent;etc)

PHONE (_____)___________________(_____)________________________________

Home Work

BIRTHDATE OF INSURED ______________________________________________

NAME OF EMPLOYER ______________________________________________________

MEDICAL INSURANCE CO. _________________________________________________

INS. CO. ADDRESS ______________________________________________________

Street City State Zip

IDENTIFICATION# _______________________________________________________

GROUP# ________________________________________________________________

Secondary Insurance:

NAME OF INSURED _________________________ Relationship ________________

(Spouse;parent;etc)

PHONE (_____)___________________(_____)________________________________

Home Work

BIRTHDATE OF INSURED ______________________________________________

NAME OF EMPLOYER ______________________________________________________

MEDICAL INSURANCE CO. _________________________________________________

INS. CO. ADDRESS ______________________________________________________

Street City State Zip

IDENTIFICATION# _______________________________________________________

GROUP# ________________________________________________________________

Section III (Medical History)

List all current medical conditions including allergies and adverse medication reactions.

List past medical conditions.

List all medications you are currently taking including dosages and the dates of the initial prescriptions and most recent refill.

Medication Dosage Initial Rx Date Last Refill Date

List a history of medications you have taken in the past including dosages and the dates of the initial prescriptions and date of last use.

Medication Dosage Initial Rx Date Last Use Date

Are you presently under the care of a physician (if yes, list name and address of physician)?

When was your last complete physical exam?

Average number and type of alcoholic beverages consumed per week?

Average number and type of caffeinated beverages consumed per week?

How much and how frequently do you use tobacco?

How much and how frequently do you use non-prescription drugs? (Please list all drugs separately)

Section IV (Treatment History)

Indicate the names, occupations, treatment dates, and the helpfulness of

professionals you have consulted for your treatment issues

Name Occupation Begin Date End Date Helpful?

Indicate the names, occupations, treatment dates, and helpfulness of mental health professionals you have consulted in your lifetime (include individual, group, couples, and family counseling as well as participation in any drug or alcohol treatment program).

Name Occupation Begin Date End Date Helpful?

Section V (Family history of mental health issues and substance use)

A) List any family history of mental health or substance abuse (including alcohol) problems in your family history. List the relationship (e.g., brother, mother, etc..) followed by the problem issue.