Lauren Lollini Counseling Services
210 South Fifth St, #101 St. Charles, IL 60174 630.677.0506
Lauren.lollini@gmail.com
Client Information Sheet
Name:
Date of Birth:
Date of First Appointment: ____________________
Email: _______________________________________
Home Address: ________________________________ Home Phone: _________________
OK TO LEAVE MESSAGE? Y N
_______________________________ Mobile Phone: _________________OK TO LEAVE MESSAGE? Y N
Insurance: ______________________________________________ (Circle One) HMO PPO POS ASO PHP
Please describe briefly what brings you to treatment: _______________________________________________
________________ _________________________________________________________________________
Everyone has trouble with some of these issues from time to time. Please check the symptoms that are
especially hard for you now, or have been in the past.
Have In
Now Past
No
Have In
Now Past
Always tired
Tearfulness/over-emotional
Don’t care about anything
No motivation
Might as well be dead
Emotionless
Feeling sad or lonely
Feeling restless
Change in appetite or weight
Irritability,
Sleeping too much
Not able to sleep
Can’t concentrate
Talking too much
Racing thoughts, too many thoughts
Easily Distracted
Sexual activity or preoccupation
Impulsive actions (spending sprees,
illegal or reckless behavior)
Poor judgment
Financial problems
Thinking about suicide
No
Anxiety attacks (shaking, sweating,
pounding heart, fear of dying or going
crazy)
Anger out of proportion to situation
Flashbacks
Nightmares
Uncontrollable, compulsive behavior
Physical problems not related to a
medical condition
Feeling good about yourself
Setting goals
Relationship issues, getting along
with others
Disturbing or unreal thoughts or
beliefs
Mood swings
Hearing voices, seeing things
Afraid you might hurt someone
Sexual identity or orientation issues
Phobias
Grief/Bereavement
Eating Disorder
Family History
Living?
Father:
Mother:
Sister(s):
Brother(s):
01/08/19
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Age or
Age at
Death
History of
Emotional
Problem?
History of
Alcohol/Drug
abuse?
Medical
Problem?
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
If yes to any, please describe
Any other family members with emotional or substance abuse problems?
Please list:
History of:
Physical Abuse
Emotional Abuse
Sexual Abuse
Rape
Domestic Violence
Other Assault/Trauma
Name:
Parents Divorced? Y / N How old were you at the time?
If divorced, who did you live with?
Previous Treatment:
Therapist/Psychiatrist/Hospital
Inpatient/Outpatient
Have you ever attempted to harm yourself or others? Y / N
Do you Smoke?
Y/N
Y/N
If yes, please describe
If yes, how much??
Do you drink caffeine? (coffee, soda)
Do you drink alcohol?
Dates
Y/N
If yes, how much?
__________________________________
If yes, how often?
How much?
Do you use any type of street drugs? Current:
Y/N
In Past: Y / N
Please Describe:
Have you ever used medications for a reason other than prescribed? Y / N
Please Describe:
Current Medications: (include dosage and who prescribes the medication)
Medical Concerns: (please describe)
Legal issues related to your mental health treatment: (please describe briefly)
Anything else?
01/08/19
_________________________________________________________________________