Psi Client Information Form (Page 3 of 6) in pdf

Client Name: ______________________________

9) Have you been in psychotherapy or been hospitalized in a psychiatric facility? (Please list names

of past therapists and hospitalizations, dates, and reason for treatment.) ______________________

________________________________________________________________________________

10) Has anyone in your immediate or extended family had a psychiatric illness? Please list

relationship and nature of illness. _____________________________________________________

________________________________________________________________________________

11) Spouse/Significant Other: ___________________________________ Age: _______________

Children (Please list names and ages): ________________________________________________

Parents (Please list names and ages): _________________________________________________

Describe your current family situation and relationship history.

________________________________________________________________________________

12) Education: ___________________________________________________________________

13) Current employment and work history (summary). ____________________________________

________________________________________________________________________________

14) Describe your relationship within your family of origin. Include parental substance abuse issues

as well as other relevant life events. ___________________________________________________

________________________________________________________________________________

15) Briefly describe your current support system (family, friends, organizations, self). ____________

________________________________________________________________________________

16) Briefly describe your strengths and weaknesses.

________________________________________________________________________________

17) Please describe your goals for therapy.

A. _________________________________________________________________________

B. _________________________________________________________________________

C. _________________________________________________________________________

18) Do you have thoughts about hurting yourself or others?  yes

 no

Please describe. ___________________________________________________________________

________________________________________________________________________________

House/forms/client history 072407 Rev 061912

Psi Client Information Form Page 3