Personal History Form CLIENT

ADULT PERSONAL HISTORY FORM

THE FAMILY GUIDANCE AND THERAPY CENTER
Please complete and return. Please submit any educational, neurological, or psychological records that you feel would benefit the therapist in learning about you.
General Information
Client name*
Todays date*

MonthDayYear
Date
Gender orientation*
Name of person completing form*
Client DOB*

MonthDayYear
Date
Preferred contact phone #*
Email address:*
example@example.com
Address*
Social Security #*
Alternative phone #
Emergency contact name:*
Emergency contact #:*
Seeking the following services:*

Relationship Development Intervention (RDI)Individual TherapyBehavioral TherapyParent TrainingCouples TherapyEducational ConsultationGroup TherapyFamily TherapyPre-Marital TherapyOther
Primary reason(s) for seeking services:*

Relational IssuesAutism SpectrumAnger ManagementWork IssueSocial IssuesParenting IssuesFamily ProblemsDevelopmental DelaysAnxietyCopingFear/PhobiasCompulsive BehaviorsDepressionSexual ConcernsAlcohol/DrugsEating DisorderSleeping ProblemsHyperactivity
Other mental health concerns (specify):*
Please select:*

American IndianAsianBlackHispanicPacific IslanderWhiteTwo or More RacesOtherI'd rather not say
Language(s) spoken at home:
Religion (if applicable):
Please answer the following questions to the best of your ability:
1. What are your goals for coming here? Please be as specific as possible.
Please indicate anything notable about your medical status, including neurological problems and allergies.*

No health issuesAbortionAsthmaBlackoutsBronchitisHivesCerebral PalsyChicken PoxCongenital ProblemsCroupDiabetesSexually Transmitted DiseaseDizzinessEar achesEar InfectionsEczemaEncephalitisFeversHay FeverHeart TroubleHepatitisHearingRheumatic FeverInfluenzaLead PoisoningMeaslesMeningititsMiscarriageMultiple SclerosisMumpsMuscular DystropNose BleedsOther Skin RashesParalysisPneumoniaPolioPregnancySpeechSensory/MotorScarlet FeverSeizuresSevere coldsHeadachesThyroid DisordersVision ProblemsWearing GlassesWhooping CoughOther
List any current health concerns*
List any recent health or physical changes:*

Current prescribed medications

	Current Prescribed Medications	Dose	Dates	Purpose	Side Effects
Medication 1
Medication 2
Medication 3
Medication 4

Current over the counter medications

	Current Over the Counter Medications	Dose	Dates	Purpose	Side Effects
Medication 1
Medication 2
Medication 3
Medication 4

Primary Care Doctor or Psychiatrist’s Name:
Primary Care Doctor or Psychiatrist’s Office Name:
Primary Care Doctor or Psychiatrist’s Address:
Primary Care Doctor or Psychiatrist’s Phone #:
3. Counseling/Prior Treatment History: Please share with me any prior counseling that you have received. What worked? What did not work?
Would you would like to provide additional information?
Upload additional records

Browse Files
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ADULT PERSONAL HISTORY FORM

General Information