Current Date

Client’s Name:

Client’s Date of birth

Client’s Social Security Number

Client’s Social Security Number

Cell #

Home #

Emergency Contact Name

Work#

Phone#

Individual’s Address

Insurance Name

Ins. Member #

Insurance Phone #

Insurance Subscriber’s DOB

Insurance Subscriber’s Phone #

Insurance Subscriber’s Name

EAP Authorization #:

Auth. Start Date

Insurance Subscriber’s Address

EAP Program

EAP Phone #:

Auth. expire Date

Client’s Employer

Hire Date

Number of sessions authorized

If full time student, Enter School

If_full_time_student,_enter_School

Position

Marital Status

If married, total number of marriages for you

Religion

List of significant others

total number of marriages for your spouse

Do you want your records to be sent to any person or organization?

General Symptoms:

Primary care Physician

If yes, to where?

Primary care Physician phone

Psychiatrist

Psychiatrist Phone

List your current medications

If so, when and how?

Have you ever been hospitalized for any mental illness or substance abuse?

Have you ever tried to harm yourself?

Please list current problems and how long you have had the problem (s) or concern (s):

What have you done or are currently doing to resolve the problem (s) or concern (s)?

What are your therapy goals?

Areas of Weakness that need Improvement:

Are there any sensory or health problems that would impair your ability to make or communicate responsible decisions? Yes / No

Leisure/Recreational

Areas of Strength that you can draw from:

If yes, describe in detail