PLEASE READ THE CONTRACT DOCUMENT BEFORE PROCEEDING TO FILL OUT THE CLIENT INFORMATION FORM CLICK HERE TO READ CLIENT INFORMATION Name * First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### Email * Age/Birthday Sexual Orientation Heterosexual? Lesbian? Gay? Bisexual? Questioning? Prefer not to answer? Education High School Degree Occupation Marital Status Single? Married? Numbers of years married Separated? Divorced? Widowed? Spouse's Name Spouse's Age Spouse's Occupation Children's Name Children's Age Children's Name Children's Age Brothers and sisters (including yourself) in birth order's Name: Brothers and sisters (including yourself) in birth order's Age: Brothers and sisters (including yourself) in birth order's Name: Brothers and sisters (including yourself) in birth order's Age: In your family, was there history of? Alcoholism? Substance Abuse? Mental Illness Do you drink alcohol? Yes No If yes, how often? Hospitalized for substance abuse/Alcoholism? Yes No Eating Disorder? Yes No Please list any disability, medical condition, physical symptoms or prolonged physical illness you would like your counselor/therapist to know about? What kind? * Current medications you are presently taking? How do you administer your medication? Morning Afternoon Bedtime Have you had previous psychiatric care/or counseling? Yes No If Yes, complete below: Sessions from and Details Is domestic violence currently an issue in your relationship? Yes No When was the last time you thought about suicide? Are you currently experiencing depression, anxiety, panic attacks? Yes No Are you currently experiencing chronic pain? Yes No Are you satisfied with your current sleeping habits? Yes No Explain Primary Physician Phone * Country (###) ### #### How were you referred to our practice? Whom may we thank for referring you? 𝐖𝐑𝐈𝐓𝐓𝐄𝐍 𝐀𝐂𝐊𝐍𝐎𝐖𝐋𝐄𝐃𝐆𝐄𝐌𝐄𝐍𝐓 𝐀𝐍𝐃 𝐂𝐎𝐍𝐒𝐄𝐍𝐓 𝐓𝐎 𝐂𝐎𝐔𝐍𝐒𝐄𝐋𝐈𝐍𝐆. * 𝐏𝐥𝐞𝐚𝐬𝐞 𝐂𝐡𝐞𝐜𝐤 𝐈 𝐡𝐚𝐯𝐞 𝐫𝐞𝐚𝐝 𝐓𝐡𝐞 𝐂𝐨𝐧𝐭𝐫𝐚𝐜𝐭 𝐃𝐨𝐜𝐮𝐦𝐞𝐧𝐭𝐬, 𝐮𝐧𝐝𝐞𝐫𝐬𝐭𝐨𝐨𝐝, 𝐚𝐜𝐜𝐞𝐩𝐭 𝐚𝐧𝐝 𝐚𝐠𝐫𝐞𝐞𝐝 𝐰𝐢𝐭𝐡 𝐚𝐥𝐥 𝐢𝐭𝐬 𝐜𝐨𝐧𝐝𝐢𝐭𝐢𝐨𝐧𝐬, 𝐚𝐧𝐝 𝐡𝐞𝐫𝐞𝐰𝐢𝐭𝐡 𝐜𝐨𝐧𝐬𝐞𝐧𝐭 𝐭𝐨 𝐜𝐨𝐮𝐧𝐬𝐞𝐥𝐢𝐧𝐠/𝐦𝐞𝐧𝐭𝐚𝐥 𝐡𝐞𝐚𝐥𝐭𝐡 𝐭𝐡𝐞𝐫𝐚𝐩𝐲 𝐚𝐧𝐝 𝐜𝐨𝐚𝐜𝐡𝐢𝐧𝐠 𝐰𝐢𝐭𝐡 𝐌𝐚𝐫𝐠𝐚𝐫𝐞𝐭 𝐑𝐨𝐬𝐞 𝐅𝐨𝐧𝐬𝐞𝐜𝐚 𝐄𝐝.𝐒., 𝐌𝐀. 𝐋𝐏𝐂, 𝐂𝐏𝐂 Date MM DD YYYY Thank you! Margaret Rose Fonseca at New Beginnings Counseling and CoachingContact New Beginnings Counseling & Coaching To Know More! Providing online counseling and coaching.
