Contact

Name

First

Last

Gender

Male
Female
Others

Religion

Christianity
Islam
Atheism
Others

Email

Current Address

Phone Number

Date of Birth

Age

Office Location

Occupation

Home Address

Status

What brings you to therapy currently?

Current Symptoms You Are Experiencing

Other Symptoms

Do you Exercise?

Yes
No

If Yes, How Often?

If Yes, How Vigorous

Do You Take Caffeine?

Yes
No

If Yes, How Often?

What Type?

Soda
Coffee
Tea

Do you take alcohol?

Yes
No

If Yes, How Often?

Do you currently live alone?

Yes
No

Have you ever attempted suicide?

Yes
No

If Yes, Number of times

Date of last attempt

Do you consider yourself to be religious or spiritual?

Yes
No

If yes, describe your faith or believe

Have you experienced an event or situation in your life that you would consider traumatic?

Yes
No

If yes, briefly describe:

If married, are you having issues in your marriage?

Primary Reason(s) for seeking Therapy currently

Other(s)

Specific Treatment Goals for Therapy

1.

2.

in having AGREEMENT

3.

4.

5.

Any Other Specific Information?

COUNSELLING AGREEMENT

CONFIDENTIALITY

COUNSELLING AGREEMENT

TIME DURATION

CANCELLATIONS

COST OF SERVICE

PLEASE TAKE NOTE OF THE FOLLOWING SESSION POLICIES

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Client Name

Date

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