Adult Client Information Form
Please take your time to fully fill out this form. It is quite detailed and can take up to 15-20 minutes. The information that you provide allows our clinicians to begin your treatment with as much information as possible-- saving you time in your initial session (and ultimately saving you money).
Name
First Name
Last Name
Pronouns
Date of Birth
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please list the names and ages of everyone who currently resides at this address with you.
Email
example@example.com
We have an email newsletter, providing additional information and support to our clients. would you like to join The Center for Living Balance mailing list?
Yes, subscribe me to this newsletter.
Phone Number
-
Area Code
Phone Number
Emergency Contact Name
First Name
Last Name
Emergency Contact Phone Number
-
Area Code
Phone Number
The Center for Living Balance will only contact your Emergency Contact if we believe it is a life or death emergency. Please type your initials below to indicate that we may do so.
How did you hear about The Center for Living Balance?
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Client History
Why are you currently seeking counseling?
What are your goals for your counseling for The Center for Living Balance?
Have you ever talked with a psychiatrist, psychologist, or other mental health professional?
Yes
No
If yes, please list your provider's name, approximate dates, and reasons for the services.
Please check the box beside any symptom that you are CURRENTLY experiencing difficulty with.
Anxiety
Depression
Mood Changes
Anger or Temper
Panic
Fears
Irritability
Concentration
Headaches
Loss of Memory
Excessive Worry
Feeling Manic
Trusting Others
Communicating with Others
Drugs
Alcohol
Caffeine
Frequent Vomiting
Eating Problems
Severe Weight Gain
Severe Weight Loss
Blackouts
People in General
Parents
Children
Marriage/Romantic Relationship(s)
Friend(s)
Co-Worker(s)
Employer
Finances
Legal Problems
Sexual Problems
History of Child Abuse
History of Sexual Abuse
Domestic Violence
Thoughts of Hurting Someone Else
Thoughts of Hurting Self
Thoughts of Suicide
Self Harm
Sleeping Too Much
Sleeping Too Little
Getting to Sleep
Waking too Early
Staying Asleep
Nightmares
Head Injury
Nausea
Abdominal Distress
Fainting
Dizziness
Diarrhea
Shortness of Breath
Chest Pain
Lump in the Throat
Sweating
Heart Palpitations
Muscle Tension
Pain in Joints
Allergies
Often Make Careless Mistakes
Fidget Frequently
Speak Without Thinking
Waiting Your Turn
Completing Tasks
Completing Tasks
Paying Attention
Easily Distracted by Noises
Hyperactivity
Chills or Hot Flashes
Flashbacks
PTSD Symptoms
Chronic Illness
Binge Eating
Impulsive Behavior
Please check the box beside any symptom that you have experienced difficulty with in the PAST.
Anxiety
Depression
Mood Changes
Anger or Temper
Panic
Fears
Irritability
Concentration
Headaches
Loss of Memory
Excessive Worry
Feeling Manic
Trusting Others
Communicating with Others
Drugs
Alcohol
Caffeine
Frequent Vomiting
Eating Problems
Severe Weight Gain
Severe Weight Loss
Blackouts
People in General
Parents
Children
Marriage/Romantic Relationship(s)
Friend(s)
Co-Worker(s)
Employer
Finances
Legal Problems
Sexual Problems
History of Child Abuse
History of Sexual Abuse
Domestic Violence
Thoughts of Hurting Someone Else
Thoughts of Hurting Self
Thoughts of Suicide
Self Harm
Sleeping Too Much
Sleeping Too Little
Getting to Sleep
Waking too Early
Staying Asleep
Nightmares
Head Injury
Nausea
Abdominal Distress
Fainting
Dizziness
Diarrhea
Shortness of Breath
Chest Pain
Lump in the Throat
Sweating
Heart Palpitations
Muscle Tension
Pain in Joints
Allergies
Often Make Careless Mistakes
Fidget Frequently
Speak Without Thinking
Waiting Your Turn
Completing Tasks
Completing Tasks
Paying Attention
Easily Distracted by Noises
Hyperactivity
Chills or Hot Flashes
Flashbacks
PTSD Symptoms
Chronic Illness
Binge Eating
Impulsive Behavior
Family Psychiatric History: Please check all of the boxes that apply
Drug/Alcohol Problems
Legal Trouble
Domestic Violence
Suicide or Suicidal Behavior
Physical Abuse
Sexual Abuse
Hyperactivity
Eating Disorder
Depression
Anxiety
Psychiatric Hospitization
Nervous Breakdown
PTSD
Please explain any significant medical problems, symptoms, or illnesses:
Please list any current medications, purpose, and name of prescribing physician:
Do you smoke or use tobacco?
Yes
No
If YES, how much per day?
Do you consume caffeine?
Yes
No
If YES, how much per day?
Do you drink alcohol?
Yes
No
If YES, how much per day/week/month/year?
Do you use any other mood altering substances or non-prescription drugs?
Yes
No
If YES, what substances and how often?
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Family History
When you were growing up and needed to talk to someone because you were upset, who did you confide in?
How would you describe your relationship with your mother?
Please provide 3-5 adjectives to describe your mother.
Is your mother still living?
Yes
No
How would you describe your relationship with your father?
Please provide 3-5 adjectives to describe your father.
Is your father still living?
Yes
No
If you have/had step-parents, please list below and describe the relationship.
Please describe your parents' relationship? Include your step-parents if relevant.
Please list and describe your relationship with any other caregivers that you had a significant relationship with.
How many brothers do you have?
How many sisters do you have?
How would you describe your relationship with your siblings?
Please share your best memory from childhood.
Please share a difficult memory or event from your childhood.
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Current Relationship History
Are you currently in a relationship?
Yes
No (you can skip to the next page)
How many years have you been in this relationship?
Are you currently married?
Yes
No
How many years have you been married?
How satisfied are you currently in this relationship?
1
2
3
4
5
6
7
8
9
10
Not satisfied at all
Highly satisfied
1 is Not satisfied at all, 10 is Highly satisfied
What factors contribute to this rating?
What is the highest level of satisfaction that you have had in this relationship?
1
2
3
4
5
6
7
8
9
10
Not satisfied at all
Highly satisfied
1 is Not satisfied at all, 10 is Highly satisfied
When were you this satisfied? What contributed to that satisfaction?
Please list the names, ages, and gender of any children from this marriage.
Please list any parenting concerns or information that would be important for your counselor to understand.
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Past Relationship History
Please list the names, ages, and gender of any children you had from previous relationships.
Please list the names, ages, and gender of any of your other children and describe the context of your relationship (adopted, fostered, guardian, etc).
Please list any significant romantic relationships from your past and how those relationships ended.
Are you a survivor of domestic abuse (physical, emotional, sexual)?
Yes
No
Unsure
Please share anything that you would like your therapist to know about the abuse.
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You've done it! This is the last page and the last question of the Client Intake Form! Please use the space below to share any additional information, questions, or concerns that you want to share with your therapist.
Which therapist(s) will you be working with?
*
Amy Jaynes, LPC, NCC, CRC
Deana Riley, LPC, CPCS
Kelly Petaccio, LPC, CPCS
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