New Client Forms (Page 2 of 2) in pdf

New Client Forms Page 2

________________________________________________________________________

Hospitalizations? Yes No

If yes, please list dates and reasons: ___________________________________________

________________________________________________________________________

Previous Counseling? Yes No

If yes, please list dates and reasons: ___________________________________________

Was it helpful? ___________________________________________________________

Do you drink alcohol or smoke marijuana? How often? ___________________________

What is your concern and reason you are here today?_____________________________

________________________________________________________________________

Please tell me your mental, emotional and/or spiritual goals for our work _____________

________________________________________________________________________

On the back side of this form, or a separate sheet of paper, please draw a time line of your life

with any significant physical, mental, emotional, or spiritual challenges you have experienced.

New Client Forms Page 2