Adult Client Information Form

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?

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.

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.

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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Client History