New Client Screening Form Page 2
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3Choices Counseling & Resource Center, PA
SCREENING FORM
MEDICAL HISTORY:
Please describe your physical health: (check one) excellent ___ good ___ fair ___ poor ___
Allergies? Yes ___ No ___ If yes, explain: __________________ Tobacco use? Yes ___ No ___
Medications:
Drug
Dosage
Purpose
Doctor
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
The remainder of this form must be completed prior to the first session or with the
assistance of your counselor. If you have questions, please ask. Clients under 18 may
opt to complete this section during the first session.
FAMILY INFORMATION
NAME
AGE
LIVING WITH YOU?
Mother
________________
________
yes ____ no ____
Father
________________
________
yes ____ no ____
Spouse/Partner
________________
________
yes ____ no ____
Siblings and/or Children
________________ ________
yes ____ no ____
________________ ________
yes ____ no ____
________________
________
yes ____ no ____
________________
________
yes ____ no ____
If married, number of years: ________
Other significant relationships (names/relationship only): ___________________________________
COUNSELING HISTORY
Have you ever been to counseling for any reason? Yes ____ No ____
If yes, for what reason? ___________________________
Who was your counselor? _________________________ How long did you attend? _______________
Have you ever been hospitalized for mental illness or substance abuse? Yes ____ No ____
If yes, for what reason? __________________________ How long were you in treatment? ____________
Facility Name: ____________________________________ Dates of treatment: _________________________
When you were discharged, did you attend outpatient counseling? Yes ____ No ____
Name of counselor: ________________________________
LIFE HISTORY (issues, circumstances, problems – past or present)
Circle all that apply and/or add anything not listed here
Losses
death of family member
divorce
separation
broken engagement
miscarriage/abortion/infertility bankruptcy homelessness
career/job Loss
Victimizations
child or spousal abuse: physical – verbal – emotional – sexual
abandonment
rape/assault
suicide/suicide attempt
major illness due to: disease or accident
physical disability
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Revised 2/2010
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Parent category: Medical