Relationships aren't easy.
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We are here to help.
New Client Survey
NANTUCKET FAMILY COUNSELING
Patient Registration Form
Kindly print, fill out and bring in at the time of your first appointment.
ALL information is kept confidential.
Date of first appointment:______________________________
Name: _________________________________________________
Date of Birth: _________________________________________
If you are here for a child, please list his/her name and date of birth.___________________________________________
Address:
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
Home Phone: _______________________
Work Phone: ________________________
Cell Phone: _________________________
E-Mail Address:______________________
Health Insurance Plan: _________________________
Telephone Number: ___________________________
I.D. Number: ________________________________
Insured’s Name: ______________________________
Insured’s Employer: ___________________________
Your Religion: _______________________
Your Occupation: _________________________________
Hours worked per week: ___________
Place of Employment: ________________________
Shift: ______________ Years:____________
Job Responsibilities:_______________________________________
Marital Status:______________ Date of Marriage: __________
Years together with partner: _____
Spouse’s/Significant Other’s first name:_____________________
List Each Child’s
Name: Age: Grade in School: Sex:
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
Were there any difficulties with any of the pregnancies or deliveries? _________________________
You do not need to answer the rest if you are here for your child.
Have you ever served in the military? _______________
If so, when? _______________________
Are there any current or previous legal charges against you? _______________________________
What do you like to do in your spare time? ____________________________________________
Do you have any special talents or hobbies? ____________________________________________
Who referred you for counseling at this time?___________________________________________
Do you drink alcohol? ________________
If so, how frequently/how much? __________________
Do you smoke marijuana? ____________
If so, how frequently/how much? ___________________
Do you use any non-prescription medications? __________________________________________
Do you have any allergies? __________________________________________
How much caffeine do you consume each day? __________________________________________
Do you smoke cigarettes? ___________________
Have you in the past? _____________________
Name of Primary Physician: _______________________
Date of last physical exam: __________
Do I have your permission to communicate with his/her office, if necessary? ___________________
Do you have any physical problems? _________________________________________________
History of Prior Surgeries: _________________________________________________
Please list any prescription medications you are currently taking:
Name:
Start Date: Dosage: Frequency:
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
Have you taken any anti-depressant medications in the past and if so, what? _____________________________________________
What were the results? __________________________________________________
Do you have trouble sleeping? __________________________________________________
How would you describe your appetite? _______________________________________________
Do you or have you ever had panic/anxiety attacks? _____________________________________
Have you ever had thoughts of suicide? _______________________________________________
Have you lost a close friend or family member through death recently?________________________
Do you have any pets? If so, please list: _______________________________________________
Do you have any family members who have suffered from emotional or psychiatric disorders? _____
If so, whom? _______________________________________________________
Did you have any learning/attention problems in school?_________________________________
What would you perceive your current stresses to be? _____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
What are some of the areas you would like to explore in therapy? _____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
Please use the following space to add any information you think may be helpful in the counseling process: _____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
Thank you for taking the time
to let me get to know you.
Patient Registration Form
Kindly print, fill out and bring in at the time of your first appointment.
ALL information is kept confidential.
Date of first appointment:______________________________
Name: _________________________________________________
Date of Birth: _________________________________________
If you are here for a child, please list his/her name and date of birth.___________________________________________
Address:
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
Home Phone: _______________________
Work Phone: ________________________
Cell Phone: _________________________
E-Mail Address:______________________
Health Insurance Plan: _________________________
Telephone Number: ___________________________
I.D. Number: ________________________________
Insured’s Name: ______________________________
Insured’s Employer: ___________________________
Your Religion: _______________________
Your Occupation: _________________________________
Hours worked per week: ___________
Place of Employment: ________________________
Shift: ______________ Years:____________
Job Responsibilities:_______________________________________
Marital Status:______________ Date of Marriage: __________
Years together with partner: _____
Spouse’s/Significant Other’s first name:_____________________
List Each Child’s
Name: Age: Grade in School: Sex:
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
Were there any difficulties with any of the pregnancies or deliveries? _________________________
You do not need to answer the rest if you are here for your child.
Have you ever served in the military? _______________
If so, when? _______________________
Are there any current or previous legal charges against you? _______________________________
What do you like to do in your spare time? ____________________________________________
Do you have any special talents or hobbies? ____________________________________________
Who referred you for counseling at this time?___________________________________________
Do you drink alcohol? ________________
If so, how frequently/how much? __________________
Do you smoke marijuana? ____________
If so, how frequently/how much? ___________________
Do you use any non-prescription medications? __________________________________________
Do you have any allergies? __________________________________________
How much caffeine do you consume each day? __________________________________________
Do you smoke cigarettes? ___________________
Have you in the past? _____________________
Name of Primary Physician: _______________________
Date of last physical exam: __________
Do I have your permission to communicate with his/her office, if necessary? ___________________
Do you have any physical problems? _________________________________________________
History of Prior Surgeries: _________________________________________________
Please list any prescription medications you are currently taking:
Name:
Start Date: Dosage: Frequency:
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
Have you taken any anti-depressant medications in the past and if so, what? _____________________________________________
What were the results? __________________________________________________
Do you have trouble sleeping? __________________________________________________
How would you describe your appetite? _______________________________________________
Do you or have you ever had panic/anxiety attacks? _____________________________________
Have you ever had thoughts of suicide? _______________________________________________
Have you lost a close friend or family member through death recently?________________________
Do you have any pets? If so, please list: _______________________________________________
Do you have any family members who have suffered from emotional or psychiatric disorders? _____
If so, whom? _______________________________________________________
Did you have any learning/attention problems in school?_________________________________
What would you perceive your current stresses to be? _____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
What are some of the areas you would like to explore in therapy? _____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
Please use the following space to add any information you think may be helpful in the counseling process: _____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
Thank you for taking the time
to let me get to know you.