Name_________________________________________________  Date____________

Address________________________________________________________________

City/State/Zip_________________________________________________________

Email________________  Hm#___________  Wk#___________  Cell#___________


Sex_____  Age_____  DOB___________  Birthplace_________________________

SS#_______________________  TXDL#__________________

Marital Status__________________  # of children______  


Employed by____________________________________________________________

Address__________________________________________________________


Referred by_______________________  May I thank them? Yes_____  No_____

Signed___________________________________________________________


Whom shall I contact in case of an emergency?___________________________

Ph#_____________________________  Relationship__________________________

Address___________________________________________________________


Primary care MD___________________________________  Ph#_________________

May I contact? Yes_____  No_____  Signed________________________________

What meds do you take?__________________________________________________

Allergies?__________________ Medical problems?__________________________


Primary reason for seeking treatment?___________________________________

________________________________________________________________________


Have you ever felt suicidal?_____  homicidal?_____  Problems with: 

anger?______ anxiety?_____  self-esteem?_____  alcohol?_____  drugs?____

food?_____  shopping?______ gambling?_____  sleep?_____  phobias?_______  

legal?_____  grief/mourning?_____  divorce?______

Have you ever been abused? If so, how?______

Other problems/concerns?________________________________________________

________________________________________________________________________