COUNSELING CLIENT INFORMATION FORM TEMPLATE

DATE	ADMINISTRATOR
IS THIS A PREVIOUS PATIENT?	REFERRED BY
PATIENT INFORMATION
NAME
CELL PHONE	HOME ADDRESS
ALT. PHONE
EMAIL
SOC SEC #	WORK ADDRESS
DATE OF BIRTH
EMERGENCY CONTACT
NAME OF CONTACT	RELATIONSHIP TO CLIENT
MAIN PHONE #	ALT. PHONE #
HEALTH INFORMATION
Describe the reason for the initial visit.
Describe your mental health in general.
Please circle any of the following conditions you've had a health issue with.
anxiety depression anger concentration phobias communication drugs/alcohol	parents children sleeping child abuse sex abuse nightmares	self-inflicted pain financial problems head injuries nausea attention trust in others worry	broken bone measles hepatitis tuberculosis neck pain diabetes artificial joints	_______________ _______________ _______________ _______________ _______________ _______________	_______________ _______________ _______________ _______________ _______________ _______________
Please specify on any conditions circled above.

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