Client Name
Client E-Mail Address
Client Phone Number
May We Leave Recorded Phone Messages
Persons That Messages May Be Left With (If Any)
Client Age
Client Date of Birth
Client Occupation
Client Address
Military Service (Branch, Rank, Disciplinary Problems, Combat Experience)
Spouse Name
Spouse Phone
List Children at Home (Name, Age)
List Children Outside the Home (Name, Age)
Has Client Received Prior Counseling?
Name of Prior Counselor
Last Date of Prior Counseling
Reason(s) for Prior Counseling
Any Other Family Members Receiving Counseling?
If So, Which Family Members?
If Other Family Members Are Receiving Counseling, State Why & with Whom
Emergency Contact 1 (Please Provide Name, Relationship, Address, Phone #)
Emergency Contact 2 (Please Provide Name, Relationship, Address, Phone #)
State the Nature of the Problem
Most Difficult Relationship Right Now
Most Difficult Emotion Right Now
What Do You Want to Gain From Counseling?
Family Mental Health History - Select Yes / No if Any Family Members Had the Below Issues & Please List Their Name / Relationship
Alcohol / Substance Abuse
If So, Which Family Members Had Alcohol Problems?
If So, Which Family Members Had Anxiety Problems?
If So, Which Family Members Had Depression Problems?
If So, Which Family Members Had Domestic Violence Problems?
If So, Which Family Members Had Eating Disorders?
If So, Which Family Members Had Obesity Problems?
Obsessive Compulsive Behavior
If So, Which Family Members Had Obsessive Compulsive Behavior?
If So, Which Family Members Had Schizophrenia?
If So, Which Family Members Attempted Suicide?
Abused/Neglected (Physical, Emotional, Sexual)
If So, Which Family Members were Abused / Neglected?
Crisis Information
Any Current Suicidal Thoughts, Feelings or Actions?
If So, Please Explain the Suicidal Thoughts, Feelings or Actions
What is Your Current Mood Right Now? On a scale of zero (0) to ten (10), with zero meaning 'life is not worth living' and ten meaning you are very opportunistic and wonderful, what number would you give your mood?
Any Past Hospitalizations or jailings for Suicidal or Assaultive Behavior?
If So, Please Explain these Problems
Any Current Threats of Signifcant Loss or Harm? (Illness, Divorce, Job Loss, Custody, etc...)
If So, Please Explain these Threats
Medical Information
Doctor's Name, Address, Phone #
Medical Insurance Company & #
Are You Currently Taking Prescription Medication?
If So, Please List Which Prescription Medications
Have You Ever Been Prescribed Psychiatric Medication?
If So, Please List Which Psychiatric Medications
Any Problems with Eating, Sleeping, Chronic Pain, Recent Weight Changes?
If So, Please Describe
Have You Ever Experienced an Abortion?
If So, How Many?
Other Medical Problems?
Spiritual History
Do You Consider Yourself to Be Spiritual or Religious?
Any Specific Denomination?
Please Describe Your Faith
How Strong is the Influence of Chruch in Your Life?
What Are Some of Your Strengths?
What Are Some of Your Weaknesses?
Adult Checklist of Characteristics
Check All That Apply
I Have No Problems or Concerns Bringing Me Here Abuse - Physical, Sexual, Emotional, Neglect (of Children or Elderly Persons), Cruelty to Animals Aggression, Violence Alcohol Use Anger, Hostility, Arguing, Irritability Anxiety, Nervousness Attention, Concentration, Distractability Career Concerns, Goals & Choices Childhood Issues (Your Own Childhood) Codependence Confusion Compulsions Custody of Children Decision Making, Indecision, Mixed Feelings, Putting Off Decisions Delusions (False Ideas) Dependence Depression, Low Mood, Sadness, Crying Divorce, Separation Drug Use - Prescription Meds, Over-the-Counter Meds, Street Drugs Eating Problems - Overeating, Undereating, Appetite, Vomiting (See Also "Weight & Diet Issues") Emptiness Failure Fatigue, Tiredness, Low Energy Fears, Phobias Financial Troubles, Impulsive Spending, Low Income Friendships Gambling Grieving, Mourning, Deaths, Losses, Divorce Guilt Headaches, Other Pains Health, illness, Medical Concerns, Physical Problems Housework, Chores-Quality, Schedules, Shared Duties Inferiority Feelings Interpersonal Conflicts Impulsiveness, Loss of Control, Outbursts Irresponsibility Judgement Problems, Risk Taking Legal Matters, Charges, Suits Loneliness Marital Conflict, Distance / Coldness, Infidelity / Affairs, Remarriage, Different Expectations, Disappointments Memory Problems Menstrual Problems, PMS, Menopause Mood Swings Motivation, Laziness Nervousness, Tension Obsessions, Compulsions Oversensitivity to Rejection Chronic Pain Panic or Anxiety Attacks Parenting, Child Management, Single Parenthood Perfectionism Pessimism Procrastination, Work Inhibitions, laziness Relationship Problems School Problems (See Also "Career Concerns") Self Centeredness Self Esteem Self Neglect, Poor Self Care Sexual Issues, Dysfunctions, Conflicts, Desire Differences, Other (See Also "Abuse") Shyness, Oversensitivity to Criticism Sleep Problems. Too Much, Too Little, Insomnia, Nightmares Smoking, Tobacco Use Spiritual, Religious, Moral, Ethical Issues Stress, Relaxation, Stress Management, Stress Disorders, Tension Suspiciousness, Distrust Suicidal Thoughts Temper Problems, Self-Control, Low Frustration Tolerance Thought Disorganization Threats, Violence Weight & Diet Issues Withdrawal, Isolating Work Problems, Employment, Workaholism/Overworking, Can't keep a Job, Dissatisfaction, Ambition Other Concerns or Issues
All About Me
Who Are You?
What Do You Want for Your Life?
Growing Up, How Did You Envision Your Life?
How Would You Describe Yourself?
What Are Your Strengths?
How Are You the Same & Different Than 5 Years Ago? 10 Years Ago?
What Areas of Your Life Would You Like to Improve?
Whose Life Do You Want to Emulate?
When You Wake Up Tomorrow and a Miracle Has Occurred in Your Life, What Would Your Life Be Like?
Who may We Thank for Referring You to TCC? (Name, Relationship, Phone #)
Please Type In Your Full Name to Electonically Sign
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