Client Information Form - Adult
Client Information Form - Adult
Name: *

First Name Last Name
Nicknames or aliases: *
Date of Birth: *

Month Day Year
Age: *
Social Security #: *
Home Street Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number: *

Area Code Phone Number
Cell Phone #: *

Area Code Phone Number
Email Address (Must be an Active Email Address) *
Calls or email will be discrete, but please indicate any restrictions: *

0/500
May we text your cell phone for appointment reminders? *

Yes No
Relationship Status: *

Single Married Divorced Domestic Partnership Widow/Widower
Number of Children: *
Your Current Employer
Employer: *
Job Title:
Employer Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Work Phone Number

Area Code Phone Number
Calls or email will be discrete, but please indicate any restrictions: *

0/500
Your Education and Training
Highest Degree/Educational Level: *

Some High School High School Technical Training Some College College Degree Graduate/Professional School
Your Medical Care: From where or whom do you get your medical care?
Clinic/Doctor's Name:
Clinic/Doctor's Phone Number:

Area Code Phone Number
Clinic/Doctor's Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Emergency Information

If an emergency arises and we cannot reach you directly, or we need to reach someone close to you, whom should we call?
1) Name: *

First Name Last Name
Phone Number: *

Area Code Phone Number
Relationship: *
Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
2) Name:

First Name Last Name
Phone Number:

Area Code Phone Number
Relationship:
Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Please describe the main difficulty that has brought you in: *

0/1000
Please list any previously diagnosed mental illness/conditions: *

Depression/Mood Anxiety OCD ADHD/ADD Bipolar PTSD Schizophrenia Addiction Eating Disorder Learning Disability Sleep Disorder Other, please list below
0/500
Do you have a family history of drug or alcohol addiction, or mental illness? *

Yes (Indicate below) Unknown No
0/1000
Have you ever received psychological, psychiatric, drug or alcohol treatment, or counseling services before? *

Yes (Indicate below) No

Have you ever attempted suicide? *

Yes No
How many times?
At what age?
Were you hospitalized?

Yes No
Name of the Hospital:
Are you currently taking medications for psychiatric or emotional problems? *

Yes No

Prescribing Physician:
Physician Phone Number:

Area Code Phone Number
Please list all medical conditions:

Diabetes Thyroid Condition Asthma/COPD High Blood Pressure Allergies Stroke Traumatic Brain Injury Sleep Apnea Seizures Arthritis Chronic Pain Other, please list below
0/1000
List all medications for medical conditions:

0/1000
History of Physical or Sexual Abuse *

I was not abused in any way. I was abused. I do not wish to answer.
As a child, were you placed in foster care or removed from your parent's care? *

Yes No
As a child, did you live with a caregiver who was mentally ill or abusing drugs or alcohol? *

Yes No
Have you ever abused drugs or alcohol? *

Yes No
Substance Type Current Use (Last 6 Months)

Alcohol Marijuana Ecstacy PCP/LSD Caffeine Heroine Steroids Tobacco Inhalants Tranquilizers Methamphetamines Cocaine/Crack Pain Killers Spice Other (please list below)
Have you ever felt the need to cut down on your drinking/drug use? *

Yes No
Have you ever felt annoyed by criticism of your drinking/drug use? *

Yes No
Have you ever felt guilty about your drinking/drug use? *

Yes No
How much beer , wine, and/or hard liquor do you consume each week, on average? *
Other drug use: Type, Amount, and Frequency per week:
Do you spend more than 5 hours per week searching for and viewing pornography online? *

Yes No
Have you spent more money for online sexual material than you planned? *

Yes No
Have you accessed sexual internet pages from other computers beside your personal electronics? *

Yes No
Are you worried you might have a problem with sexual behavior and/or internet pornography use? *

Yes No
Are you concerned about your partner/spouse's sexual behavior or pornography use? *

Yes No
I understand that a typed version of my name maybe accepted as my original signature pursuant to the Georgia Uniform ElectronicTransactions Act (O.C.G.A. 10-12-7). To accept the above statement, type"I Understand" in the box below. *
Signature (Please Type Full Name) *
Date *

Month Day Year
Signature *

In order for this submission to be accepted, you must use your mouse and draw your signature in the box above. Clear
Should be Empty:

Client Information Form - Adult