| Personal Information |
| Name: |
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| Parent/Legal Guardian (if under 18): |
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| Address: |
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| Home Phone: |
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May we leave a message? |
Yes
No
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| Cell/Work/Other: |
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May we leave a message? |
Yes
No
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| Email: |
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May we send a message? |
Yes
No
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| *Please note: Email correspondence is not considered to be a confidential medium of communication. |
| Date of Birth: |
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| Age: |
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| Gender: |
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| Marital Status: |
Never Married
Domestic Partnership
Married
Separated
Divorced
Widowed
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| Referred by: |
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| What are the reasons you are seeking therapy at this time? |
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| What significant life changes or stressful events have you experienced in the last 1 – 2 years (death, divorce, move, job change, etc.)? |
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| How would you like to see your life change as a result of your therapy at Inner Light Counseling? |
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| Are you currently employed? |
YES
NO
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| If yes, what is your current employment situation? |
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| Do you enjoy your work? Is there anything stressful about your current work? |
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| Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc.)? |
NO
YES, previous therapist/practitioner:
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| Are you currently taking any medical and/or psychiatric prescription medication? |
YES
NO
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| If yes, please list name, dosage, & frequency: |
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| Name of Primary Care Physician/Pediatrician? |
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| Phone Number |
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| Address |
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| Name, address, phone number of child’s school counselor? (if applicable) |
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| Name of person to be contacted in case of emergency? |
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| Phone number: |
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| How would you rate your current physical health? (please circle one) |
Poor
Unsatisfactory
Satisfactory
Good
Very Good
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| Please list any specific health problems you are currently experiencing: |
|
| How would you rate your current sleeping habits: |
Poor
Unsatisfactory
Satisfactory
Good
Very Good
|
| Please list any specific sleep problems you are currently experiencing (trouble falling asleep, waking up, etc.): |
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| Please list any difficulties you experience with your appetite or eating problems: |
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| Are you currently experiencing overwhelming sadness, anger, grief, or depression? |
Yes
No
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| If yes, for approximately how long? |
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| Are you currently experiencing anxiety, panic attacks, or have any phobias? |
Yes
No
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| If yes, when did you begin experiencing this? |
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| Are you currently experiencing any chronic pain? |
Yes
No
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| If yes, please describe: |
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| Do you drink alcohol more than once a week? |
Yes
No
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| How often do you engage in recreational drug use? |
Daily
Weekly
Monthly
Infrequently
Never
|
| History of allergic disorders? |
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| Family Mental Health History |
| Please answer & list family member |
| Alcohol/Substance Abuse |
Yes
No
|
Family Member: |
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| Anxiety |
Yes
No
|
Family Member: |
|
| Depression |
Yes
No
|
Family Member: |
|
| Domestic Violence |
Yes
No
|
Family Member: |
|
| Eating Disorders |
Yes
No
|
Family Member: |
|
| Obesity |
Yes
No
|
Family Member: |
|
| Obsessive Compulsive Behavior |
Yes
No
|
Family Member: |
|
| Schizophrenia |
Yes
No
|
Family Member: |
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| Suicide / Suicide Attempts |
Yes
No
|
Family Member: |
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| Other |
Yes
No
|
Family Member: |
|
Client Signature:
(or parent/guardian if applicable) |
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| Date |
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