Personal Information and Medical Consent Form
(Please fill in and print out and form for first session)
Name: ________________________ Date:
____________
Age: ________ Marital Status: Single _____ Married _____
Divorced Widowed______
Childrens Names Ages and Gender if apllicable___________________________________________________________
Pleae tell me why you are coming for therapy at this time:___________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
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Please indicate if you are experiencing any of these symptoms:
depression ( ) sadness or grief ( )moodiness/irritability( )
Anxiousness ( ) lonliness( ) stress ( ) tiredness
Tension ( ) sleep disturbance ( ) low energy
( )
Nightmares ( ) work difficulties ( ) change of appetite (
)
Please explain: _______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Are you feeling suicidal? yes ( )no ( )Homocidal: yes ( ) no
( )
Please explain: _______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Do you have a problem with alcohol or drugs? yes ( ) no (
)
Please explain:________________________________________________________________________________
What medications are you currently taking, why you are taking them, and dosage and frequency.
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Are you experiencing any medical problems at this time? yes ( )
no ( )
Please explain: _______________________________________________________________________________________
_______________________________________________________________________________________ _______________________________________________________________________________________
If so, what physician are you seeing for this? ( Please provide name, address and phone numbers)
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Please describe any current or past involvement with the legal system (civil or criminal ):
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
What is your highest level of education?
Pre High School ( ) High School GED ( ) Associates
Degree ( ) Bachelor's Degree ( ) Master's Degree Doctoral
Degree ( ) Currently Enrolled in College ( )
What is your field of study? ___________________________
Are you happy with your educational or employment choices? yes ( ) no (
)
Please explain: ______________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Please describe briefly your spiritual beliefs and needs if any: _____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Have you been involved in counseling, therapy, or substance abuse treatment? yes (
) no ( )
Please indicate when with whom and how helpful it was: _________________________________________________________________________________
______________________________________________________________________________________
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______________________________________________________________________________________
Please describe your relationship with your family of origin: ______________________________________________________________________________________
______________________________________________________________________________________
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______________________________________________________________________________________
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Do you have hobbies or interests? Please explain: ______________________________________________________________________________________
______________________________________________________________________________________
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How you would describe yourself as a person? ______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Thank you for your efforts in providing this information. It is very helpful in getting the therapy sarted
quickly. This information is strictly confidential and will never be released to anyone without your permission
accept where required by law.