new client form - adult · inge r. schnee, msw, lmft, lsw 35 north gate road mendham nj 07945 p:...
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IngeR.Schnee,MSW,LMFT,LSW
35NorthGateRoadMendhamNJ07945
P:908-380-6813F:[email protected]
New Day For You
NewClientForm
Pleasenote:Theinformationyouprovidehereisprotectedasconfidentialinformation.
Name:_______________________________________________________________________________
Address:_____________________________________________________________________________
_____________________________________________________________________________________
BirthDate:______/______/______Age:________Gender:□Male□Female
□NeverMarried□DomesticPartnership□Married□Separated□Divorced□Widowed
Pleaselistanychildren/age:____________________________________________________________________________________
____________________________________________________________________________________
HomePhone:()MayIleaveamessage?□Yes□No
Cell/OtherPhone:()MayIleaveamessage?□Yes□No
E-mail:_________________________________________MayIemailyou?□Yes□No
*Pleasenote:Emailcorrespondenceisnotconsideredtobeaconfidentialmediumof
communication.
Referredby:(ifany)
_____________________________________________________________________________________
Haveyoupreviouslyreceivedanytypeofmentalhealthservices?
□No
□Yes,previoustherapist/practitioner:
_____________________________________________________________________________________
Areyoucurrentlytakinganyprescriptionmedication?
□Yes□No
Pleaselist:____________________________________________________________________________
Haveyoueverbeenprescribedpsychiatricmedication?
□Yes□No
Pleaselistandprovidedates:_____________________________________________________________________________________
_____________________________________________________________________________________
Areyoucurrentlyemployed?□Yes□No
Ifyes,whatisyourcurrentemploymentsituation?
_____________________________________________________________________________________
Areyounotworkingbychoice?
_____________________________________________________________________________________
Whatsignificantlifechangesorstressfuleventshaveyouexperiencedrecently?
_____________________________________________________________________________________
_____________________________________________________________________________________
Doyouconsideryourselftobespiritualorreligious?□Yes□No
Ifyes,describeyourfaithorbelief:
_____________________________________________________________________________________
Whatwouldyouliketoaccomplishoutofyourtimeintherapy?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
PLEASECHECKANYOFTHEFOLLOWINGPROBLEMSWHICHMAYPERTAINTOYOU
____NERVOUSNESS
____SHYNESS
____SEPARATION
____DRUGUSE
____ANGER
____SLEEP
____DEPRESSION
____SEXUALPROBLEMS
____DIVORCE
____ALCOHOLUSE
____SELF-CONTROL
____STRESS
____BEINGAPARENT
____HEADACHES
____FEARS
____RELAXATION ____MEMORY
____LEGALMATTERS
____ENERGY
____LONELINESS
____EDUCATION
____TEMPER
____CHILDREN
____BOWELTROUBLE
____APPETITE
____INSOMNIA
____INFERIORITYFEELINGS
____CAREERCHOICES
____NIGHTMARES
____CONCENTRATION
____HEALTHPROBLEMS
____SUICIDALTHOUGHTS
____SUICIDEATTEMPTS
____AMBITION
____MAKINGDECISION
____FINANCES
____FRIENDS
____UNHAPPINESS
____WORK
____TIREDNESS
____MARRIAGE
____STOMACHTROUBLE
____MYTHOUGHTS
____Grief
Inthesectionbelow,pleasecircleifanymemberofyourfamilyhasexperiencedanyofthefollowingproblems:(pleaseindicatethefamilymember’srelationshiptoyou-grandmother,uncle,etc.)
PleaseCircleandidentifythefamilymember
Alcohol/SubstanceAbuseyes/no
EatingDisordersyes/no
Anxietyyes/no
Domesticviolenceyes/no
Obesityyes/no
ObsessiveCompulsiveBehavioryes/no
Schizophreniayes/no
Bipolarillnessyes/no
SuicideAttemptsyes/no
AdditionalInformation:__________________________________________________________________
_____________________________________________________________________________________
Yoursignatureplease_____________________________________________
Thankyoufortakingthetimetocompletethisform.