GENERAL INFORMATION Name:__________________________________________________ Today's Date ___________________
Address:___________________________________ City:__________________ State:____ Zip:________ Home Phone (____)_______________ Cell # (____)________________ Work Phone (____)____________ E-mail Address (please print clearly):________________________________________________________ Date of Birth:___________ Age:_____ Marital/Partnership Status:____________Gender: ____F ____M Educational Background: ___________________________Occupation:____________________________ Any Known Learning Disabilities:__________________________________________________________ Emergency Contact: Name/Relationship_______________________________ Phone(____)___________ Who referred you to this office? _____________________________________________________ FAMILY SYSTEM INFORMATION
HEALTH AND MEDICAL INFORMATION Are you currently being treated by a physician? _____yes _____no If yes, for what purpose?
Date of your last completed physical examination:__________ Do you have any chronic medical or physical conditions? _____yes _____no If yes, what are they and how do they affect you?
Please list all prescription and non-prescription medications you are now taking:
Please note any significant current or past health issues:
OTHER INFORMATION What is you current living situation? (e.g, living alone, with parents, roommates, partner, spouse, children, etc.)
What prior experience do you have with counseling or psychotherapy?
What other information do you think would be of value to me in providing services to you?
What, specifically, would you like to accomplish as a result of working with me?
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