New-Client FormsPrint these forms, fill in and mail to:
Sue Johnston, 12 Lakeview Court, Orangeville, Ontario, Canada, L9W 4P2
Personal and Family Record
To make our first meeting more productive, please give accurate and complete responses to every section of this form. If necessary, write additional information in the margins. Just a reminder that all information is confidential and will be used as background material for sessions only.
Date: __________________________
Client Name: ______________________________________________
Age:____Birth date:_____________
Address:_________________________________________________City:__________________
State/Province:____________________________
Zip/Postal code:___________________
Phone (home):______________________(work)_________________________
Employment:________________________________________________
Circle last year of school competed: 9 10 11 12 GED College: 1 2 3 4 Other:________________________________________________________________________
Marital Status: single ___ never married ____ engaged ___
living together without marriage ___
separated ____ how long? ____ divorced ____ how long? ____ widow/er ___
how long? ___, Married ____ Spouse name ________________ Age ___
Occupation ____________________
How long married to this spouse? ____ Are you happy in this marriage? ____
Previously married? ____ Total number prior marriages for you _____
For your spouse _____
List the names of your Children, their age, sex, relationship to You? Do they still live in your home? ______________________________________________________________________________
_________________________________________________________________________________
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Counseling History
Have you ever been to Counseling for any reason? Yes ____ No ____
What reason? _________________________________________________
How long?_______
Are you presently working with any other Counselor or Psychologist? Yes ____ No ____
What reason? ___________________________________________
How long? _____________
Are you involved in any other marriage counseling, family counseling, or support groups?
Yes ____ No ____ Specify _____________________________________________________
Briefly state the nature of the problem as you see it: _____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
What do you want/hope to gain from counseling? (IE: what are your goals?)
____________________________________________________________________________
_____________________________________________________________________________
Medical Information
Do you have a family Physician? Yes ____ No ____
Psychiatrist/Psychologist? Yes ____ No ____
Are you taking any prescription drugs? Yes ____ No ____
If yes, state the drug name(s), type, and for what purpose: ______________________________________
Who prescribed the drug(s)? ______________________________________________________
How often do you see this doctor? _________________________________________________
Describe your physical health: excellent ___ good ___ adequate ___ poor ___
Have you ever been hospitalized for mental illness or substance abuse? Yes ____ No ____
If yes, for what reason? __________________________________________________________
How long were you in treatment? _________________________________________________
Hospital name? ____________________________
How long ago? ______________________
Did you continue with outpatient counseling? Yes ____ No ____
Impact of Life Circumstances
Circle any LOSSES that you have experienced:
Death of:
spouse, child, father, mother, sister, brother, grandmother, grandfather, friend.
Divorce, Separation, Broken engagement, Suicide, Miscarriage, Abortion, Infertility, Bankruptcy, Homelessness, Career or job loss,
Other:________________________________________________________________
Circle any VICTIMIZATIONS you have experienced or been involved with:
Child abuse: physical, emotional, sexual, incest
Spouse abuse: physical, emotional, sexual
Abandonment, Rape, Robbery, Assault, Suicide attempt,
Auto or industrial accident, Major illness,
Surgery, Physical disability, Alienation,
Other: _________________________________________________________________
Circle any PROBLEMS that concern you now:
Relationship(s) with: Spouse, Children, Parents, In-laws, Co-workers, Friends, Teachers,
Alcohol, Street drugs, Prescription drugs, Binge eating, Excessive dieting or exercise,
Shopping, Work too much, Procrastination, Communication, Depression, Anger, Grief,
Gender identity, Sex, Career, Loneliness, Mood swings,
Self-esteem, Codependency, Stress,
Fear, Anxiety, Feelings about church or God,
Other: ___________________________________________________________________
Intense Emotional Distress
Current Situation:
Suicidal thoughts, plans, attempts _________________________________________________
Homicidal thoughts, plans, attempts _______________________________________________
Desire to cause pain to self or to others ____________________________________________
In fear for your life or personal safety ______________________________________________
Too depressed to care for self or family _____________________________________________
In signing below, I affirm that the information given on this form is true and complete. I understand
that payment for services is expected prior to each session, that upon receipt of payment the counselor
(Sue Johnston) has an obligation to me to keep all agreed upon appointments and a commitment to help
me through the process of counseling. I hereby consent to treatment and affirm that this financial
assignment has been explained to me. I agree to abide by these terms.Signature: ________________________________________
Date: _____________________