Davis Counseling

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Today’s Date


Name                                                          Age                             Date of Birth_________________________________


Address_____________________________________________________________________________________________


Phone priimary:                                                      Phone secondary___________________________________________


E Mail_______________________________________________________________________________________________


Race                                                               Where did you grow up?_________________________________________

Marital/Relationship Status______________________________________________________________________________


Education                                                                       Occupation                                   SSN_____________________


Partner’s Name                                                           Age                   Occupation________________________________


Religion(background, beliefs, involvement)_________________________________________________________________

 

Emergency Contact/Phone number/relationship______________________________________________________________


Closest Relationships      age        sex           relationship                              living with you


Name_______________________________________________________________________________________________


Name_______________________________________________________________________________________________


Please describe your current living situation:(do you live with others?)____________________________________________


____                                                                                                                                                                           _

I would describe my friendships as:      ____close    _____somewhat close _        _distant __       _conflicted________other


Have you participated in therapy before?           Y            N  Reason:_____________________________________________

____________________________________________________________________________________________________

Are you currently seeing a psychiatrist?         Y               N
Have you or a family member ever been hospitalized for mental or emotional issues?             Y              N


If yes, please explain: dates, where,reason:________________________________________________________________

___________________________________________________________________________________________________

Substance abuse or addiction history?  ___ N ___Y (please explain)______________________________________________

____________________________________________________________________________________________________

Legal History (arrests , prison , DWI ?)_____________________________________________________________________


MEDICAL INFORMATION: Doctor’s name and phone:__________________________________________________________


Are you on any medications? ___Y ___N If so, what, how much, why ?___________________________________________


PRESENTING PROBLEM: State the nature of the problem in your own words:_______________________________________

 _____________________________________________________________________________________________________

_____________________________________________________________________________________________________


Your most difficult relationship is________________________________________________________________________

Your most difficult emotion is___________________________________________________________________________

What are your two most important goals for therapy ?

1._________________________________________________________________________________________________

2._________________________________________________________________________________________________


FAMILY INFORMATION: How many siblings do you have?________

How would you describe your relationship?_________________________________________________________________


Describe your relationship with your mother and father:______________________________________________________

___________________________________________________________________________________________________

CRISIS INFORMATION: Any current suicidal thoughts, feelings or actions ? Y________ N__________


If yes, explain________________________________________________________________________________________


___________________________________________________________________________________________________

 

Significant losses?_____________________________________________________________________________________


___________________________________________________________________________________________________

Anything else you feel important that I should know about?____________________________________________________

___________________________________________________________________________________________________

___________________________________________________________________________________________________

 Who refered you to this practice ? _______________________________________________________________________

Thank you for taking the time to fill out this information sheet. This will be reviewed and used to best assist you in your psychotherapeutic work.