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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