EMU Psychology Clinic
Adult Client Application
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Today Month Day
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Year
 Contact and Demographic Information
Full Name
Birth Month
Address
/
/
Day
Year
City, State, ZIP Code
Phone Number (Cell)
Special Calling Instructions?
Phone Number (Home)
Special Calling Instructions?
Phone Number (Work)
Special Calling Instructions?
Gender (please select one):
 Male
 Female
 Other (please specify):

Race or Ethnicity (mark all that apply):
 White
 Black/African-American
 Hispanic/Latino/Chicano
 Arab/Middle-Eastern
 Other (please specify):

Religious Affiliation (please select one):
 Christian: Protestant
 Christian: Catholic
 Christian: Nondenominational
 Jewish
 Muslim
 None
 Other (please specify):

 Yes  No
OK to leave msg?
 Yes  No
OK to leave msg?
 Yes  No
OK to leave msg?
 Transgender
 Don’t know/Unsure/Prefer Not to Answer
 Asian
 Native American/American Indian/Alaska Native
 Native Hawaiian/Pacific Islander
 Don’t Know/Unsure/Prefer Not to Answer
 Hindu
 Buddhist
 Spiritual/Personal Beliefs
 Atheist
 Agnostic
 Don’t Know/Unsure/Prefer Not to Answer
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Adult Client Application (Rev. 5/15)
Sexual Orientation (please select one):
 Straight/Heterosexual
 Gay/Lesbian/Homosexual
 Bisexual
 Other (please specify):

 Asexual
 Questioning
 Don’t Know/Unsure/Prefer Not to Answer
 Mental Health
How did you learn about the EMU Psychology Clinic?
Please briefly describe the kinds of problems you are experiencing that have led you to seek treatment.
Do these problems make it hard to manage your daily responsibilities? This would include things like keeping
bathed and groomed, cooking for yourself, getting to places you need to go, managing money, keeping your
living space organized, etc. If so, please describe.
What are your goals for treatment—what do you want to achieve, make better, or be able to do?
Right now, what are the major sources of stress in your life?
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Adult Client Application (Rev. 5/15)
Right now, what has helped you cope, or “kept you going?”
When did your main problem start? Please specify a month and year—if
you’re not sure or don’t remember exactly, try to give your best estimate.
Month
/
Year
Did the main problem start after some specific event that happened to you, or did it seem to come along on
its own? Did it come on gradually or all at once? When or how did you first notice it? Please describe.
Has anything in particular happened recently to cause you to seek help right now?
This section asks about any thoughts or behaviors related to harming yourself or others. Please indicate if
you have experienced any of these things within the past month, within the past year, over a year ago, or
never—so, if you’ve had these experiences during more than one of these time periods, indicate so (mark all
that apply):
Have you had thoughts about wishing
you were dead, or thinking it would be
better if you weren’t around?
 Past Month
 1-12m Ago
 Over 1yr Ago
 Never
Have you had specific thoughts about
killing yourself?
 Past Month
 1-12m Ago
 Over 1yr Ago
 Never
Have you done things to prepare to kill
yourself, like acquire pills or weapons, or
given things away, or written a note?
 Past Month
 1-12m Ago
 Over 1yr Ago
 Never
Have you made a suicide attempt?
 Past Month
 1-12m Ago
 Over 1yr Ago
 Never
Have you deliberately harmed yourself
without intending to end your life (such
as by cutting or burning yourself)?
 Past Month
 1-12m Ago
 Over 1yr Ago
 Never
Have you had urges to physically harm
or kill another person?
 Past Month
 1-12m Ago
 Over 1yr Ago
 Never
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Adult Client Application (Rev. 5/15)
Please indicate if you’re currently struggling with any of the following issues (mark all that apply):
 Yelling at people
 Risk-taking/endangering others
 Throwing or breaking things
 Stealing
 Physically hurting others
 Internet use or misuse
 Binging on food
 Overspending/compulsive shopping
 Intentionally vomiting
 Sexual feelings/behaviors
 Exercising excessively
 Dangerous or unsafe driving
 Gambling
 Don’t Know/Unsure/Prefer Not to Answer
If you checked any of the boxes in this section—indicating that you’ve had thoughts of or experiences with
harming yourself or others, or you’re struggling with any harmful or risky behavior—please explain briefly
here. You can also describe any other harmful behaviors you think might be an issue for you, even if you
didn’t note them above.
 Substance Use
This section asks about substance use. In the left column, please indicate how much you are using
currently—in about the past month or so. In the right column, please indicate how much you used during a
period of time when you were using the most.
The first section asks about alcohol—first, please report the number of days a month that you consumed
alcohol, and when you did, about how many drinks you had on an average day. One “drink” is equal to one
can/bottle of beer, one glass of wine, or one shot of hard alcohol. Please also fill in details for the sections for
other drugs or substances, if applicable.
Alcohol
Cigarettes
Other
Tobacco/
Nicotine
Past Month
Maximum Use
Days a month you drink:
Days a month you drank:
Average number of drinks on days you drink
Average number of drinks on days you drank
Days a month you smoke:
Days a month you smoked:
Average number of cigarettes smoked per day
Average number of cigarettes smoked per day
Days a month you used:
Days a month you used:
Average amount used per day
Average amount used per day
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Adult Client Application (Rev. 5/15)
Marijuana
Days a month you use:
Days a month you used:
Average hours spent high/under the influence per day
Average hours spent high/under the influence per day
If you use—or have used in the past—any other drugs or substances, please also describe them here. This
would include illegal drugs, as well as legal or prescription drugs used more than as prescribed. There are
four spaces provided to report up to four other kinds of drugs—please use the space at the left to specify
which drug you are describing. Remember, in the left column, please indicate how often you are using
currently—in about the past month or so. In the right column, please indicate how often you used during a
period of time when you were using the most.
Drug
Drug
Drug
Drug
Past Month
Maximum Use
Days a month you use:
Days a month you used:
Days a month you use:
Days a month you used:
Days a month you use:
Days a month you used:
Days a month you use:
Days a month you used:
Have you experienced problems in any of these areas due to alcohol or drug use (mark all that apply)?
 Employment/work
 Romantic/Dating/Marriage Relationship
 School
 Legal
 Financial
 Physical Health
 Social
 Mental Health
 Family
 Don’t Know/Unsure/Prefer Not to Answer
If you checked any of the boxes above—indicating that you’ve had problems in some area of life due to
alcohol or drug use—please explain briefly here.
Has anyone—such as a friend, family member, partner, doctor, or co-worker—ever expressed concern to you
about your use of alcohol or drugs?
 No
 Yes (please explain):


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Adult Client Application (Rev. 5/15)
 Economic and Occupational Information
What is the current annual income of the household in which you reside (please select one)?
 Greater than $150,000
 $25,000 to $49,999
 $100,000 to $149,999
 $10,000 to $24,999
 $75,000 to $99,999
 Less than $10,000
 $50,000 to $74,999
 Don’t Know/Unsure/Prefer Not to Answer
What is the current economic status of the household in which you reside (please select one)?
 Plenty of “luxuries”
 Barely enough to get by
 Plenty of “extras”
 Very poor, not enough to get by
 Solidly middle-class
 Don’t Know/Unsure/Prefer Not to Answer
Do you—or does a member of your household—receive any of the following kinds of government benefits or
assistance (mark all that apply)?
 Food assistance/Food stamps
 Social Security Disability/SSI
 Cash assistance/”Welfare” benefits  VA Disability Compensation
 HUD/Public housing
 Unemployment benefits
 Child care assistance
 Any other kind of benefit or assistance
 Medicaid
 Don’t Know/Unsure/Prefer Not to Answer
Employment Status (please select one):
 Employed, Full-Time
 Employed, Part-Time
 Self-Employed
 Unemployed, Looking for Work
 Unemployed, Not Looking
 Other (please specify):

 Occasional, Non-Regular Worker/Laborer
 Disabled
 Retired
 Stay-at-Home Parent or Other Caretaker
 Don’t Know/Unsure/Prefer Not to Answer
If you are currently employed, please use the following spaces to describe your place, or places, of
employment, or other work that you do. Please name the place of employment, what your title is or what
kind of work you do there, how many hours in an average a week you work at that place, and how long you
have worked there.
Place of Employment
Title/Duties/Role
Hours/wk
Employed Since
Month
Month
Month
/
/
/
Year
Year
Year
Are you currently having any difficulties at work (or finding work) due to mental health/emotional struggles?
 No
 Yes (please explain):


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Adult Client Application (Rev. 5/15)
 Educational Information
Are you currently a student (please select one)?
 Yes, a part-time student
 Yes, a full-time student
 No
 Don’t Know/Prefer Not to Answer
From this list, please check all of the studies you have completed, and if you are in school, please check the
one you are currently pursuing. If applicable, please also list your academic major or area of study.
High school diploma
GED
Trade degree/certificate
Associate’s Degree
Bachelor’s Degree
Graduate Degree
 Completed
 Completed
 Completed
 Completed
 Completed
 Completed
 Pursuing
 Pursuing
 Pursuing
 Pursuing
 Pursuing
 Pursuing
During your past educational experiences, were you generally (please select one):
 An “A” student
 A “B” student
 A “C” student
 A “D” student
 An “F” student
 Don’t Know/Unsure/Prefer Not to Answer
During your past educational experiences, did you (mark all that apply):
 Frequently get into trouble
 Have difficulty paying attention or concentrating
 Have difficulty completing tests or assignments
 Become nervous about tests or assignments
 Frequently forget about or misplace assignments or other work
 Have difficulty making friends or fitting in socially
 Don’t Know/Unsure/Prefer Not to Answer
If you checked any of the boxes above—indicating that you’ve had problems in your educational
experiences—please explain briefly here.
Do you have any difficulties reading?
 No
 Yes (please specify): 
Do you have any difficulties writing?
 No
 Yes (please specify): 
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Adult Client Application (Rev. 5/15)
Do you have any difficulties with math?
 No
 Yes (please specify): 
Are you currently having any difficulties in school due to mental health/emotional struggles?
 No
 Yes (please explain):


 Social Life and Relationships
Please describe your current social life by checking the statements that are true for you (mark all that
apply):
 I have a group of friends in the area
 I have friends outside of the area
 I see or hang out with my friends frequently
 I talk to my friends frequently on the phone, via e-mail, etc.
 I can rely on friends for favors or help with things
 I can speak to friends about serious things
How many people are there who would hang out or do fun things with you?
How many people are there whom you could call and ask for a favor?
How many people are there whom you could talk to about important things?
Are you currently having any difficulties in your social life (or pursuing a social life, making friends, etc.) due to
mental health/emotional struggles?
 No
 Yes (please explain):


Current Marital/Relationship Status (please select one):
 Single (you can skip the next several questions)
 In any kind of relationship (e.g., dating, married, etc.)
 Don’t Know/Prefer Not to Answer
If you are currently in a relationship of any kind, please describe your relationship situation and, if applicable,
describe the length of the relationship (please select one):
 In a “Dating” Relationship (Please specify length of relationship)
 In a “Long-Term” Relationship (Please specify length of relationship)
 Engaged (Please specify length of relationship)
 Married (Please specify length of marriage)
 Married but Separated (Please specify length of marriage)
 Don’t Know/Unsure/Prefer Not to Answer
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Adult Client Application (Rev. 5/15)
Current Partner’s Gender (please select one):
 Male
 Transgender
 Female
 Don’t know/Unsure/Prefer Not to Answer
 Other (please specify):

Is your current relationship monogamous?
 Yes
 No (please explain):


Past Marriages (mark all that apply)
 Divorced (Please specify number of times)
 Widowed (Please specify number of times)
Are you currently having any difficulties in your primary romantic/dating/marriage relationship (or pursuing
relationships) due to mental health/emotional struggles?
 No
 Yes (please explain):


 Family History
There are a number of lines here for you to describe your family and close relations. Fill in a line for each
relationship that you have had; otherwise, leave it blank. If the line can refer to more than one kind of
relationship (e.g., brother or sister), circle one at the start of the line. Either write in the individual’s current
age or, if deceased, year of death (under the “YOD” heading). Indicate if you feel that your relationship with
them right now is good, fair, or poor. Finally, check the box at the end if you live with that person more than
half the time. There are additional lines at the end if there are other important family or close relations in
your life.
Name
Age
Relationship
Live With
Mother
 Good  Fair  Poor
 Yes
Father
 Good  Fair  Poor
 Yes
Stepmother
 Good  Fair  Poor
 Yes
Stepfather
 Good  Fair  Poor
 Yes
Partner/Spouse
 Good  Fair  Poor
 Yes
Partner/Spouse
 Good  Fair  Poor
 Yes
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YOD
Adult Client Application (Rev. 5/15)
Brother/Sister
 Good  Fair  Poor
 Yes
Brother/Sister
 Good  Fair  Poor
 Yes
Brother/Sister
 Good  Fair  Poor
 Yes
Brother/Sister
 Good  Fair  Poor
 Yes
Brother/Sister
 Good  Fair  Poor
 Yes
Brother/Sister
 Good  Fair  Poor
 Yes
Child/Stepchild
 Good  Fair  Poor
 Yes
Child/Stepchild
 Good  Fair  Poor
 Yes
Child/Stepchild
 Good  Fair  Poor
 Yes
Child/Stepchild
 Good  Fair  Poor
 Yes
Child/Stepchild
 Good  Fair  Poor
 Yes
Child/Stepchild
 Good  Fair  Poor
 Yes
Child/Stepchild
 Good  Fair  Poor
 Yes
Child/Stepchild
 Good  Fair  Poor
 Yes
 Good  Fair  Poor
 Yes
 Good  Fair  Poor
 Yes
 Good  Fair  Poor
 Yes
 Good  Fair  Poor
 Yes
Person
Person
Person
Person
Whom were you mostly raised by (e.g., biological parents, parent and step-parent, adoptive parents)?
Whom in your family do you currently feel closest to?
What was your biological parents’ marital status during your childhood (mark all that apply)?
 Unmarried, did not live together
 Divorced
 Unmarried, lived together
 Widowed
 Married
 Remarried
 Separated
 Don’t Know/Unsure/Prefer Not to Answer
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Adult Client Application (Rev. 5/15)
Check the statements below that describe the type of family you grew up in (mark all that apply):
 Overly close with each other
 Scared to make mistakes
 No privacy/”breathing room”
 Distant/all “did their own thing”
 Didn’t spend much time together  Comfortably close family
 Verbal abuse/name-calling
 Had a lot of fun together
 Lots of anger/fighting/conflicts
 Felt loved and cared for
 Parents always working/busy
 Felt safe in the home
 Boundaries not respected
 Shared many positive experiences
 Violence/physical abuse
 Supportive
 Basic needs not met
 Don’t Know/Unsure/Prefer Not to Answer
Did your family go through any significant, disruptive events that affected you as a child (for instance, moves
to another city, major injuries/illnesses or deaths, natural disasters, crime)? If so, please explain.
Has anyone in your immediate family ever experienced problems with mental illness, or made a suicide
attempt, or committed suicide? If so, please explain.
 Abuse History
In this section the column on the left refers to things others have done to you; the column on the right refers
to things you have done to others (mark all that apply):
Happened to You
Please indicate if you ever been:
 Physically abused
 Sexually abused
 Emotionally abused
Done by You
Please indicate if you have ever:
 Physically abused someone else
 Sexually abused someone else
 Emotionally abused someone else
Please indicate if, in the past year, you have been
hit, kicked, punched, or hurt by:
 Your partner or spouse
 Someone else you know (acquaintances,
 co-workers, bosses, etc.)
 Someone you didn’t know
Please indicate if, in the past year, you have
kicked, punched, or hurt:
 Your partner or spouse
 Someone else you know (acquaintances,
 co-workers, bosses, etc.)
 Someone you didn’t know
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Adult Client Application (Rev. 5/15)
Are you currently living in a situation where you
have been hit, kicked, punched, hurt, or threatened,
or you otherwise feel unsafe?
 No
 Yes
If you checked any of the boxes in this section, or indicated that you are living in a situation in which you feel
unsafe, please explain briefly here:
 Mental Health Treatment History
Have you ever received therapy or counseling from a psychologist, therapist, social worker, or counselor?
 Yes (please answer the follow-up questions under this heading)
 No
If so, how many different times have you participated in therapy/counseling?
If so, from when to when did you last participate in therapy/counseling?
/
Month Year
–
/
Month Year
Has any therapy treatment, at any time in the past, taken place at this clinic?  Yes
 No
Has any therapy treatment, at any time in the past, taken place at
Counseling and Psychological Services (CAPS) at EMU’s Snow Health Center?  Yes
 No
Do you know what “kind” of therapy/counseling you’ve received (e.g., CBT, psychoanalysis, etc.)?
If you’ve ever received therapy or counseling, please briefly describe your experience with it, including
some of the problems or issues you worked on.
Has therapy/counseling been helpful for you?
 None
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 A little
 Somewhat
 Very
Adult Client Application (Rev. 5/15)
Have you ever been prescribed medication of any kind to help with your emotions (like sadness or
anxiety) sleep, or attention?
 Yes (please answer the follow-up questions under this heading)
 No
If you have ever taken psychiatric medication of any kind (medication to help with your emotions,
sleep, or attention), please use the spaces here to describe your use of the medication. Record the
name of the drug (most drugs have two names—you can put down either one, and guess if you’re
not sure), the reason you were taking it, and from when to when (month and year) you started and
stopped taking it (put “present” if you’re still taking it).
Drug Name
Reason
Dates Taken
/
–
/
–
/
–
/
–
/
–
/
–
Month Year
Month Year
Month Year
Month Year
Month Year
Month Year
/
Month Year
/
Month Year
/
Month Year
/
Month Year
/
Month Year
/
Month Year
If you’ve ever taken psychiatric medication, please briefly describe your experience with it.
Has psychiatric medication been helpful for you?
 None
 A little
 Somewhat
 Very
Have you ever attended any kind of support group for a mental health or substance use problem?
 Yes (please answer the follow-up questions under this heading)
 No
If so, how many different kinds of groups have you attended?
If so, from when to when were you last attending a group?
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/
Month Year
–
/
Month Year
Adult Client Application (Rev. 5/15)
If you’ve ever attended a support group, please name the groups, and briefly describe your
experience with them.
Have support groups been helpful for you?
 None
 A little
 Somewhat
 Very
Have you ever been hospitalized, or received inpatient treatment, due to a mental health issue?
 Yes (please answer the follow-up questions under this heading)
 No
If so, how many times have you been hospitalized/in inpatient treatment?
If so, from when to when were you last hospitalized/in inpatient treatment?
/
Month Year
–
/
Month Year
If you’ve ever been hospitalized or received inpatient treatment due to a mental health issue, please
briefly describe your experience with it.
Has inpatient treatment been helpful for you?
 None
 A little
 Somewhat
 Very
 Physical Health
What is your dominant hand (please select one)?
 Right
 Left
 Ambidextrous
Do you have any difficulties seeing?
 No
 Yes (please specify): 
Do you have any difficulties hearing?
 No
 Yes (please specify): 
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Adult Client Application (Rev. 5/15)
Have you ever had any of the following experiences or medical issues (mark all that apply)?
 Concussion/being knocked out
 Stroke
 Traumatic brain injury (TBI)
 Brain aneurysm
 Brain tumor
 Seizure (with or without epilepsy diagnosis)
 Meningitis/Encephalitis
 Don’t Know/Unsure/Prefer Not to Answer
 Other neurological issue (please explain):


About how many hours of sleep do you get on an average weeknight (or, night
before you have to wake up on time for work/school/other responsibilities)?
About how many hours of sleep do you get on an average weekend night (or,
night before you can sleep without needing to get up early)?
About how long does it take you to fall asleep on an average night?
Do you have difficulties with sleep, like trouble falling asleep or waking up during the middle of the night, or
other difficulties like trouble breathing while sleeping, sleepwalking, or having nightmares?
 No
 Yes (please explain):


Recently, about how many hours or minutes of moderate physical activity (e.g.,
brisk walking, yard work, housework, easy cycling) do you do weekly?
Recently, about how many hours or minutes of vigorous physical activity (e.g.,
running, weight training, competitive sports, heavy labor) do you do weekly?
What was your highest adult weight (not including pregnancy)?
What is your current weight?
How tall are you?
Pounds
Pounds
Feet
,
Inches
Are you concerned that you’re not eating a healthy diet, or about your weight or eating habits?
 No
 Yes (please explain):


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Adult Client Application (Rev. 5/15)
How many times (approximately) have you lost 20 pounds or more (when you weren't sick) and then gained
it back (please select one)?
 Never
 Once or twice
 Three or four times
 Five times or more
 Don’t Know/Unsure/Prefer Not to Answer
Do you often eat within any 2 hour period what most people would regard as an unusually large amount of
food? Sometimes people refer to this as “binge eating.” Do you tend to do that often?
 Yes
 No
During the times when you have eaten this way, do you often feel you can’t stop eating or can't control what
or how much you were eating?
 Yes
 No
On average, how often do you eat large amounts of food, plus feel that your eating was out of control?
There may be some weeks when it was not present—just average those in (please select one):
 Less than one day a week
 One day a week
 Two days a week
 Three days a week
 Four or five days a week
 Nearly every day
 Don’t Know/Unsure/Prefer Not to Answer
Do you usually have any of the following experiences during those occasions (mark all that apply)?
 Eating much more rapidly than usual
 Eating until you felt uncomfortably full
 Eating large amounts of food when you didn’t feel physically hungry
 Eating alone because you were embarrassed by how much you were eating
 Feeling disgusted with yourself, depressed, or very guilty after overeating
 Don’t Know/Unsure/Prefer Not to Answer
When was the last time you had a checkup or appointment with a physician?
Month
/
Year
Please provide the name, office name, and phone number of your primary care physician, if you have one:
Physician’s Name
Physician’s Office
Phone Number
Please provide the name, address, relationship, and phone numbers for a person you would like to be
contacted in case of a medical or other emergency.
Emergency Contact Person’s Name
Relationship with You
Emergency Contact Person’s Full Address, City, State, and Zip
Phone Number
Phone Number (Alternate)
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Adult Client Application (Rev. 5/15)
Please describe any medical problems or conditions (e.g., cancer, diabetes, epilepsy, high blood pressure,
etc.) that you have. Please also describe any kind of treatment (including prescribed or over-the-counter
medication or supplements) that you may be receiving for them.
Medical Condition
Treatment
Please describe any major illnesses or injuries you may have had in the past, which may have required
surgery or hospitalization, and any kind of treatment you received.
Major Illness/Injury
Treatment
On a scale of 0 (no pain) to 10 (worst pain possible), how much physical pain
do you experience on a daily basis?
On a scale of 0 (none) to 10 (extreme interference), how much does physical
pain interfere with your daily activities?
Is your everyday life affected in any other ways by any of the medical issues described above? If so, please
explain.
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Adult Client Application (Rev. 5/15)
OFFICE USE ONLY; CLIENT, PLEASE DO NOT WRITE BELOW
Clinician Review and Summary of Client Application:
Clinician, Signature
Date
Clinician, Print Name
Supervising Clinician, Signature
Date
Supervising Clinician, Print Name
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Adult Client Application (Rev. 5/15)