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CLIENT INFORMATION
Race/Ethnicity
Name

Address
Date of Birth

Telephone

Email
RELATIONSHIP STATUS
EMPLOYMENT
INSURANCE INFORMATION
Insurance Co.

Member ID#

Group #
(if applicable)
FAMILY
Spouse/Age

Child/Age

Child/Age
Child/Age

Child/Age

Child/Age
MEDICAL INFORMATION
Current Medications

Current Medications

Current Medications

Current Medications

Current Medications
Primary Care Physician

Physician's Phone #

Date of Last Visit

Allergies

Medical Problems
CHECK ANY OF THE FOLLOWING THAT APPLY TO YOU
Trouble Sleeping

History of Sexual Abuse

Financial Problems

Problems at Work

Health Problems
Depression

Grief

ADHD

Panic Attacks

Anger Problems
Relationship Problems

Legal Problems

Phobia(s)

Suicidal Thoughts

Hallucinations
Sexual Problems

Anxiety
HISTORY OF COUNSELING
Name of Therapist/Agency

Dates of Counseling

Reason for Counseling

Was this Successful?
Name of Therapist/Agency

Dates of Counseling

Reason for Counseling

Was this Successful?
Briefly Describe Your Reason(s) for Seeking Help
What Would you Like to Accomplish in Counseling
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