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Full Name

Date of birth

Age *

Gender *

Preferred Pronouns:

Address

Street Address

City

State

Country

Postal Code

Phone *

Email *

Emergency Contact Name *

Emergency Contact Phone *

Relationship to Client *

Insurance Information (if applicable)

Insurance Provider:

Policy Number:

Group Number:

Policy Holder Name:

Policy Holder Date of Birth:

Presenting Concerns

Reason for seeking counseling:

How long have these concerns been present?

Have you received counseling before? If yes, briefly explain:

Mental Health History

Previous mental health diagnoses (if any):

Previous psychiatric hospitalizations:

Current therapist or psychiatrist (if applicable):

Current medications and dosages:

Past medications:

Medical History

Primary care physician:

Current medical conditions:

Past surgeries or major illnesses:

Current medications (non‑psychiatric):

Substance Use

Alcohol Use

Tobacco use:

Recreational drug use:

Prescription medication misuse:

History of substance treatment:

Family Mental Health History

Family history of depression:

Family history of anxiety:

Family history of substance abuse:

Family history of suicide attempts:

Other relevant family mental health concerns:

Trauma History

Have you experienced emotional abuse?

Have you experienced physical abuse?

Have you experienced sexual abuse?

Other traumatic experiences you wish to disclose:

Social & Lifestyle Information

Marital/Relationship status:

Children (names and ages):

Occupation/School:

Living situation:

Support system (friends/family):

Hobbies or interests:

Risk Assessment

Have you had thoughts of harming yourself?

Have you attempted suicide in the past?

Have you had thoughts of harming others?

Do you currently feel safe?

Consent & Signature

I certify that the information provided is accurate to the best of my knowledge.

Client Signature

Clear

Date