New Patient Registration
Client Information
Clients Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Social Security Number
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone
*
-
Area Code
Phone Number
Home telephone
-
Area Code
Phone Number
Other Phone
-
Area Code
Phone Number
Client Race/Ethnicity
Client Gender
*
Male
Female
Other
Pronouns
Languages Spoken
Email
*
example@example.com
May we leave a confidential message? If yes please select any that apply
*
Home phone
Cell Phone
Email
Other
Is the client under the age of 18?
*
Yes
No
Client employment status
Full time
Part time
Unemployed
Full time student
Part time student
Other
ONLY complete if client is a minor Parent/Guardian Information
Who has custody of the child? *if both parents, both must sign consent for services*
Mother/Parent Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State
Zip Code
Phone Number
-
Area Code
Phone Number
Relation to client
SSN
Employment Status
Employed full time
Employed part time
Retired
Disabled
Unemployed
Other
Employer
If other please explain
Highest Grade Completed
Income
Relationship Status
Married
Living with partner
Separated/Divorced
Widowed
Single
Other
Partners Name
If other please explain
Father/Parent Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Relation to client
SSN
Employment Status
Employed full time
Employed part time
Retired
Disabled
Unemployed
Other
Employer
If other please explain
Highest Grade Completed
Income
Relationship Status
Married
Living with partner
Separated/Divorced
Widowed
Single
Other
Partners Name
If other please explain
Parent/Guardian Military History?
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Insurance
Does client have insurance?
*
Yes
No
Policy Holder Name
*
First Name
Last Name
Policy Holder Date of Birth
*
-
Month
-
Day
Year
Date
Policy Holder Social Security Number
*
Insurance Name
*
Insurance Phone Number
-
Area Code
Phone Number
ID Number
*
Group Number
*
Does client have a secondary insurance?
*
Yes
No
Policy Holder Name
*
First Name
Last Name
Policy Holder Date of Birth
*
-
Month
-
Day
Year
Date
Policy Holder Social Security Number
Insurance Name
*
Insurance Phone Number
-
Area Code
Phone Number
ID Number
*
Group Number
*
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Who referred client to JTW Counseling?
Is client required to receive counseling as part of a legal proceeding?
*
Yes
No
Emergency Contact
*
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Relation to client
Education
CLIENT If minor: Current Grade
CLIENT If minor: Current School
CLIENT If minor Has client ever repeated a grade?
Yes
No
CLIENT If minor: Does client receive special education services (IEP)?
Yes
No
Other school difficulties
Highest Level of Education Completed
Other agencies client or family are involved with:
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Family Status & History
Client lives with:
*
Current household members
Name
Age
Relation to client
1
2
3
4
5
6
CLIENT has client ever... (check all that apply)
*
Been in foster care
Been adopted
Been cared for/lived with someone other than you
N/A
Other
Client was adopted?:
Age at adoption
does client know that they are adopted?
Yes
No
Siblings
*
Name
Age
Gender
Type
Live with?
1
Male
Female
Biological
Adopted
Step
Foster
Other
Full time (4+ days)
Part time (1-3 days)
Visits
2
Male
Female
Biological
Adopted
Step
Foster
Other
Full time (4+ days)
Part time (1-3 days)
Visits
3
Male
Female
Biological
Adopted
Step
Foster
Other
Full time (4+ days)
Part time (1-3 days)
Visits
4
Male
Female
Biological
Adopted
Step
Foster
Other
Full time (4+ days)
Part time (1-3 days)
Visits
Military History within family
Religious/Spiritual Affiliation
*
Has client ever experienced...
*
Physical abuse
Emotional abuse
Neglet
Sexual trauma
None
Are you currently concerned for your safety or minor client's safety?
*
Yes
No
Are you currently concerned for the safety of other household members?
*
Yes
No
Has anyone in client's family had current or past drug/alcohol abuse?
*
Yes
No
Who?
CLIENT I use/have used the following...
*
Never
Sometimes
Always
For how long?
Alcohol
Nicotine (cigarettes, chewing tobacco or E-Cigarettes)
Cannabis (marijuana/hash)
Cocaine
Crack
Heroin
Prescription pain medicine (Vicodin, Hydrocodone etc.)
Methamphetamines (Meth)
Sedatives (ex. Valium, Klonopin)
Stimulants (ex. Adderall, Ritalin)
Caffeinated or Energy Drinks (Red Bull etc)
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Family Status & History
Current Marital/Relationship Status
Years together
Number of marriages
If applicable, year divorced/separated
Are you sexually active?
Current
Past
Never
Have you ever been pregnant/fathered a child?
Yes
No
Number of pregnancies
Number of births
Are you a Parent/Currently parenting/ Have children?
Yes
No
Number of children
Children
Name
Age
Gender
Type
Live with?
1
Male
Female
Biological
Adopted
Step
Foster
Other
Full time (4+ days)
Part time (1-3 days)
Visits
2
Male
Female
Biological
Adopted
Step
Foster
Other
Full time (4+ days)
Part time (1-3 days)
Visits
3
Male
Female
Biological
Adopted
Step
Foster
Other
Full time (4+ days)
Part time (1-3 days)
Visits
4
Male
Female
Biological
Adopted
Step
Foster
Other
Full time (4+ days)
Part time (1-3 days)
Visits
Minor and Adult client: Are both of your parents still living?
Yes
No
please specify
Were your parents' married/cohabitate?
Yes
No
Are they still?
Yes
No
Years together
Briefly describe your parent(s)/caregiver(s)
Have you ever experienced
*
Physical abuse
Emotional abuse
Neglect
Sexual trauma
Other
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Personal & Family History
Has client ever been hospitalized for a psychiatric illness?
*
Yes
No
If Yes, when?
Has a relative ever been hospitalized for a psychiatric illness?
*
Yes
No
If Yes, who and when?
Has client ever been diagnosed with a behavioral health/mental health condition?
*
Yes
No
If Yes please complete the following
What was the diagnosis
By Whom
When was the diagnosis
1
2
3
Does anyone in client's family have a behavioral health/mental health condition?
*
Yes
No
If Yes please complete the following
Who
What was the diagnosis
By whom
1
2
3
Has anyone that client knows ever attempted suicide?
*
Yes
No
If yes, who and when?
Has anyone that client knows ever completed suicide?
*
Yes
No
If yes, who and when?
Does anyone in client's family have a substance abuse problem?
*
Yes
No
If yes, who?
Has anyone that client knows ever been arrested ?
*
Yes
No
If yes, who and when?
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Health History
Does client have a PCP?
*
Yes
No
Would you like assistance finding one?
*
Yes
No
Provider's Name
First Name
Last Name
Provider's Number
-
Area Code
Phone Number
Date of last visit
-
Month
-
Day
Year
Date
Would you like JTW Counseling to share information with your PCP?
*
Yes
No
Signature
Name of Dentist
Dentist phone
-
Area Code
Phone Number
Date of last visit
-
Month
-
Day
Year
Date
Health Conditions
Client
Family
Migraines, headaches or dizziness
Heart attack
Digestive issues
Skin problems
Head trauma
High/Low blood pressure
Thyroid problems
Seizures
Stroke
Vision problems
Condition
Diabetes
Hearing loss
Asthma
Cancer
Neurological disorder
Has client ever been diagnosed with a Medical Condition/Illness?
*
Yes
No
Medical Condition/Illness
*
Diagnosed/Treated by
Date/Year
Is client currently receiving care due to medical condition/illness?
Has client ever taken any medications (psychotropic medications, vitamins, supplements, OTC)?
*
Yes
No
Name of Medication
Dosage
How often is it taken?
Purpose
Currently taking
Any allergies to food, environmental, medication? Please list
*
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Child Development
Was pregnancy planned?
Yes
No
When did the mother obtain prenatal care?
Did mother experience any of the following while pregnant?
Accident
Exposure to chemicals
Serious illness
None
What medications or drugs were used during pregnancy
Mother's age at birth
Father's age at birth
Length of pregnancy
Weeks
Birth weight
lbs, oz
Length of labor
Child's condition at birth
Mother's condition at birth
If client is adopted please provide adoption history
Age that client...
Sat
Crawled
Walked
Toilet trained day
Toilet trained night
Talked
1
2
3
4
5
6
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Current Concern(s)
What things brings client most joy/happiness?
*
What is client good at hobbies?
What are your family's strengths?
What is your presenting problem/brings you to counseling at this time?
*
What do you hope will be different as a result of counseling?
*
Completed by:
*
First Name
Last Name
Relation to client
*
Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: