Suzette M. Stoks, Ph.D.
Clinical Psychologist, Texas License #31775
Phone: (210) 654-1900; Email: connect@suzettestoks.com; Website: www.suzettestoks.com
CLIENT INFORMATION FORM
Today's date:
Your name:
Date of birth:
Age:
In case of emergency , I have your permission to call the following person(s):
Their phone numbers & relationship to you:
Referral: Who gave you my name to call? Name:
Phone:
May I have your permission to thank this person for the referral? • Yes • No
Chief Concern
Please describe the main difficulty that has brought you to see me:
What are the main ways that you have tried to address this difficulty?
What has worked the best for you, even if it is not the healthiest for you?
What would success in this area look like for you?
Mental Health Treatment History
1. Have you ever received psychological or psychiatric or counseling services before?
• No • Yes
2. Have you ever taken medications for psychiatric or emotional problems? • No • Yes
3. Have you ever tried taking over-the-counter vitamins or herbal supplements for emotional problems? • No • Yes
4. Please list all medication, vitamins, and/or herbal supplements you are currently taking:
Your medical care: From whom or where do you get your medical care?
Clinic/doctor's name:
Phone:
If you enter treatment with me for psychological problems, may I tell your medical doctor so that he or she can be fully
informed and we can coordinate your treatment? • Yes • No
Education/Training/Work History
1. What is your highest level of education (Grade or Degree)?
2. Have you ever been in the military? • Yes • No. If yes, highest rank attained?
3. What jobs & positions have you held in the past?
4. Your Current Employer:
Position:
Personal History
How many brothers & sisters do you have?
How many step- or half-siblings do you have?
How many marriages or long-term relationships did your parents have?
Are you currently in a long-term relationship or marriage?
How many long-term relationships or marriages have you had?
How many children do you have? Ages?
Of your parents and siblings that have passed away, what were the reasons for their death?
What have been the most important or difficult events in your life?
Present relationships
As applicable:
1. How do you get along with your present spouse or partner?
2. How do you get along with your children?
3. How do you get along with your parents?
Health habits
1. What kinds of physical exercise do you get?
2. How much coffee, cola, tea, or other sources of caffeine do you consume each day?
3. Do you try to restrict your eating in any way? How? Why?
4. Do you have any problems getting enough sleep?
5. Are there any other medical or physical problems you are concerned about?
Substance use
1. Have you ever felt the need to cut down on your drinking? • No • Yes
2. Have you ever felt annoyed by criticism of your drinking?
• No • Yes
3. How much beer, wine, or hard liquor do you consume each week, on the average?
4. How much tobacco do you smoke or chew each week?
5. Which drugs (not medications prescribed for you) have you used in the last 10 years, either regular or experimental use?
Abuse history: *Please be aware that the State of Texas may require me to report any abuse that occurred to you as a child, even
if it has already been reported!
• I was not abused in any way.
• I choose not to answer this question
• I was abused. Please indicate which: • Physical • Sexual • Verbal • Emotional • Neglect
Relationship of Abuser(s) to you:
Impact of this abuse on your life:
Legal history
1. Are you presently suing anyone or thinking of suing anyone? • No • Yes
2. Is your reason for coming to see me related to an accident or injury? • No • Yes
3. Are you required by a court, the police, or a probation/parole officer to have this appointment? • No • Yes
4. Are there any other legal involvements I should know about?
Other
Do you have a belief system that you would like to incorporate as part of your therapy?
Is there anything else that is important for me as your therapist to know about, and that you have not written about on any
of these forms? If yes, please tell me about it here or on another sheet of paper:
The information I have reported above as truthful as I can recall.
Date
Signature
Patient Contact Information Sheet
This form is designed to make contacting you easy for you and for me, and done in a way that is respectful of
your privacy. Please fill in the information below.
PLEASE PRINT THIS INFORMATION LEGIBLY
Your name:
Your current address:
Your current home telephone number: (
)
If you are unavailable, may I leave a message on an answering machine or with someone else who answers
the phone at your home?
YES
NO
Do you have a cell phone that I may use to contact you? If so, please provide the number below:
(
)
May I leave a message on your cell phone or with someone else who answers? YES
NO
Do you have a work phone number that I may use to contact you? If so, please provide the number:
(
)
May I leave a message on your voicemail or with someone else who answers at work? YES
NO
Do you have email? Please note that email is NOT a completely secure and confidential way to communicate.
If we correspond by email, I will do my best to maintain your confidentiality in the text of what I say. However, if
you are not comfortable with some risk, please do not use email for correspondence. I will typically not
correspond with you via email unless you email me first. If you would like me to possibly use email to contact
you, you may provide your email address:
What are the best times and ways to reach you?
Is there anything else you would like me to know about contacting you?
Patient Signature
Date