Psi Client Information Form Page 2
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6PsychStrategies
Client History, Concerns and Goals
Name of Client:__________________________________________
Date: ________________
(If you have come for Couples Therapy, please fill out one form for each partner.)
Filled out by: ____________________________
Relationship to Client: ___________________
Please fill in the following information as completely as possible. All information is covered by our
confidentiality policy (see Office Policies). Use the back of form as necessary.
1) Describe what has happened recently that led you to seek counseling now. _________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
2) Describe current concerns and symptoms. ___________________________________________
________________________________________________________________________________
________________________________________________________________________________
3) Check the one response which best applies:
(A) My current concerns and symptoms are:
(B) My current symptoms developed:
the continuation of a long-standing condition
suddenly (less than four weeks)
a recent worsening of an on-going condition
gradually (one to several months)
the reoccurrence of a previous condition
very gradually (one to several years)
significantly different from any previous condition
my first occurrence of any condition
4) Medical History. Please list major injuries, illnesses or surgeries.
Condition
Dates
Treatment
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
5) Are you currently on any medication? yes
no
Medication
Dosage
Prescribing Physician
Date Started
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Allergies/Sensitivities to medications ___________________________________________________
6) Are there any psychiatric medications you have taken in the past (and are not currently taking):
Medication
Dosage
Prescribing Physician
Date Started
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
7) Please indicate any significant prenatal events and developmental history. __________________
________________________________________________________________________________
8) Please list other substances that you use. Include amount and frequency.
Alcohol ___________________________________
Heroin ______________________________________
Marijuana _________________________________
Psychedelics__________________________________
Caffeine __________________________________
Methamphetamine _____________________________
Tobacco (cigarettes, etc.) ____________________
Other _______________________________________
House/forms/client history 072407 Rev 061912
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