Date
*
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Name
*
First Name
Last Name
Birth date
*
MM
DD
YYYY
Address
*
Email
*
Phone
*
(###)
###
####
Who referred you?
What would you like to see happen as a result of counseling?
*
Gender
Relationship status:
Dates of Service
Military Branch
Employment
Employer
What type of work do you do?
Mother Living (age)
Mother Deceased (date)
MM
DD
YYYY
Father Living (age)
Father Deceased (date)
MM
DD
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How many Siblings do You have?
I am the:
Names and ages of your children
Names and ages of step children
Have you or anyone in your family ever experienced domestic violence or abuse?
If yes, please explain:
Are you currently experiencing domestic violence or abuse?
Religion/Denominational Preference:
Church
List any physical illness or symptoms you are having at this time:
List current medications (include dosages and physician prescribing)
Check all that you have experienced in the last month:
Explain
What else are you experiencing at this time?
Have you experienced mental health problems before?
If yes, please explain:
Do you have a family history of mental health issues?
Have you ever received outpatient treatment (counseling, therapy, psychiatrist) for mental health issues?
If yes, when and where?
Have you ever been hospitalized or received inpatient treatment for mental health issues?
If yes, when and where?
Have you wished you were dead, or wished you could go to sleep and not wake up?
*
Have you had any actual thoughts of killing yourself?
*
Do you have a plan to kill yourself?
*
Have you ever attempted suicide?
*
If yes, number of attempts
Have you ever lost someone you care about to suicide?
If yes, who and when?
Do you drink alcohol?
Do you currently use drugs (illegal drugs, recreational drugs, drugs not prescribed to you, or drugs used in excess of how they are prescribed), or do you have a history of using drugs?
If yes, which ones?
Do you have a history of, or currently use intravenous (IV) drugs?
Have you ever received outpatient treatment (counseling, therapy, psychiatrist, or medication) for an alcohol or substance use problem?
If yes, when and where?
Did you successfully complete the outpatient treatment?
Have you ever received inpatient treatment (hospitalization, detox, rehab, sober living) for an alcohol or substance use problem?
If yes, when and where ?
Did you successfully complete the inpatient treatment?
Are you coming in for a current alcohol or substance addiction?
*
Did a staff member from RPC refer you? If so who?
*
What other information might be important for your therapist to know?
Signature of Client
*
Today's Date
*
MM
DD
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