PERSONAL DATA
(Information will be held confidential)
Name____________________________________________________________Date________________________
Age____________ Date of birth______________________Marital Status________________________________
Address____________________________________________________Zip Code__________________________
Home Phone______________________________________Mobile Phone________________________________
Employer________________________________________ Business Phone_______________________________
Occupation______________________________________________Education_____________________________
Emergency contact ___________________________ Relationship_________Phone _______________________
Spouse (including common-law)
and ex-spouses
Date of Marriage/
Living Arrangement
Date of Divorce or
Separation
Spouse’s age _______ Spouse’s Occupation_________________________________ Education_____________
YOUR FAMILY:
Father’s Name _________________________________ Age_______ Occupation__________________________
If deceased, date_____________ cause_______________________________________ age___________ at death
Mother’s Name _________________________________ Age_______ Occupation_________________________
If deceased, date_____________ cause_______________________________________ age___________ at death
SIBLINGS:
Name
Age Marital
Name
Age Marital
Status
Status
WITH WHOM ARE YOU NOW LIVING?
Name
Age Relationship
CHILDREN LIVING AWAY FROM HOME:
Name
Age
Occupation or School and Grade
Living with whom and where
Date of last physical exam________________________ Physician _____________________________________
Height __________ Weight (clothed) _________ Recent weight changes_________________________________
Nutritional supplements ________________________________________________________________________
Medications (including non-prescription) with dosages_______________________________________________
_____________________________________________________________________________________________
List and date all major accidents, illnesses, and hospitalizations
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
AVERAGE DAILY INTAKE:
Alcohol
Tobacco
Caffeine
Marijuana
Non-prescription drugs
Type and Frequency of Exercise _________________________________________________________________
MARK ANY OF THE FOLLOWING WHICH APPLY TO YOU:
 Headaches
 Heart palpitations
 School problems
 Irritability
 Restlessness
 Family problems
 Fatigue
 Overeating
 Poor appetite
 Vomiting
 Bowel problems
 Excessive sleep
 Guilt
 Compulsions
 Suicidal ideas
 Brooding
 Preoccupations
 Unwanted thoughts
 Fainting
 Frequent worries
 Difficulty relaxing
 Insomnia
 Hallucinations
 Unusual experiences
 Loneliness
 Legal difficulties
 Past court involvement
 Dizziness
 Drug problem
 Drinking too much
 Depression
 Sexual problems
 Difficulty making friends











Memory problems
Thoughts racing
Problems concentrating
Inferiority feelings
Difficulty making decisions
Past suicide attempts
Stomach trouble
Difficulty trusting people
Employment problems
Problems with anger
Difficulty keeping friends
Others _______________________________________________________________________________________
Approximate date of onset of problems with which you are now concerned ______________________________
Persons or agencies you have previously consulted about your problems _______________________________
_____________________________________________________________________________________________
Current referring agency _______________________________________________________________________
Please list the goals you would like to accomplish in treatment ________________________________________
_____________________________________________________________________________________________
Other information which might be pertinent to your treatment
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________