New Client Paperwork

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NANTUCKET FAMILY COUNSELING

New Client Paperwork

Kindly print, fill out and bring in at the time of your first appointment.

ALL information is kept confidential. Thank you!

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: ___________________________ Date of Birth:__________________
Insured’s Employer: _________________________
Your Religion: ________________Do you attend church?__________________________
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 you involved in any litigation at the present time? ___________________________________
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, when and what? ___________________________________________________________________
What were the results? _____________________________________________________
Do you have trouble sleeping? _________________________________________________
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. I am so excited to begin working with you.

NANTUCKET FAMILY COUNSELING