Client Information Form Today's Date MM DD YYYY Date of first Session MM DD YYYY Name * First Name Last Name Prefer to be called Date of Birth MM DD YYYY SS# Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Home Phone (###) ### #### Work Phone (###) ### #### Cell Phone (###) ### #### Ok to leave message * Yes No Ok to text? * Yes No Email * Employer * Occupation Emergency Contact * Please include name, phone and relationship Checkbox In case of concern for your life and safety, or the life and safety of others, your counselor may decide to notify the emergency contact person listed above. I understand and accept this. How were you referred to the Center? Select 2 May we contact the person who referred you to thank them? Yes No Age Birthplace Number of siblings Your birth order Present marital status: Single Married Separated Divorced Widowed Partnered How long? Highest Education Grade/Degree Completed Gender Male Female Ethnicity Faith Preference Spouse/Partner Name First Name Last Name Spouse/Partner Age Length of Relationship Children Please list your child(ren)'s name and age What concerns bring you to counseling at this time? Symptoms Please check those that apply to you today and the past two weeks: Anger/Aggression Alcohol or Drug Abuse/Other Addictions Depression Anxiety Loss of interest in activities or life Impulsivity Inattention Self Esteem Issues Suicidal Thoughts Sense of Helplessness or Hopelessness Irritability Loneliness Memory Problems Dizziness Headaches Mood Swings Sexual Difficulties Trauma Stress Sleeping Difficulties Eating Disorder Fatigue Worry Grief/Loss Marital/Relationship Issues Family Conflicts Parent/Child Difficulties Weight Gain/Loss Other Counseling Goals Please share up to 4 goals you are hoping to work toward in your counseling. Substance Use History Alcohol Frequency: Never Daily Weekly Monthly Number per week Do you currently use other drugs (marijuana, cocaine, ecstacy, heroin)? Yes No If yes, frequency Do you abuse prescription drugs? Yes No If yes, frequency? Have you ever abused any controlled substance? Yes No Please provide any helpful information: Medical/Mental Health History Are you currently being treated for any medical conditions? Yes No If yes, please describe: List current medications or supplements and dosages you are currently taking. List Prescribing Physician(s) and Phone Previous Counseling: When and with whom? What do you like best about yourself? I have read Wellspring's Practices and Procedures. * Can be found Here: https://wellspringcounselingplanofumc.com/client-forms Yes I have read Wellspring's Notice of Privacy. * Can be found Here: https://wellspringcounselingplanofumc.com/client-forms Yes I have read Wellspring's Client Consent Form * Can be found Here: https://wellspringcounselingplanofumc.com/client-forms Yes I have read Wellspring's Teletherapy Consent Form * Can be found Here: https://wellspringcounselingplanofumc.com/client-forms Yes Thank you!
