Client History Form

Client History

Name______________________________________________ DOB_______________

Presenting Problem(s) – use your own words __________________________________

_______________________________________________________________________

_______________________________________________________________________

Previous Psychotherapy - give approximate dates, duration and therapist name _______

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Medical History

Primary Physician ________________________________ Last visit_______________

List any ongoing health issues ______________________________________________

_______________________________________________________________________

Current Medications _______________________________________________________

Supplements/Vitamins/Herbal medications ____________________________________

_______________________________________________________________________

Hospitalization History (including mental health issues) ________________________

_______________________________________________________________________

Have you ever had a head injury? Yes No

Have you ever had a seizure? Yes No

Have you ever had a stroke? Yes No

Substance Use History

(Circle all that apply. Indicate previous and/or current, frequency, and quantity)

Caffeine (e.g., colas, coffee, tea, etc.) ________________________________________

Tobacco ______________________________________________________________

Alcohol _______________________________________________________________

Marijuana _____________________________________________________________

Psychedelics ___________________________________________________________

Cocaine________________________________________________________________

Opiates ________________________________________________________________

Others _________________________________________________________________

Family Mental Health/Medical History

(Circle all that apply. Indicate which family member)

Depression _____________________________________________________________

Anxiety ________________________________________________________________

Panic attacks ____________________________________________________________

Phobias ________________________________________________________________

Mania/Bipolar disorder ____________________________________________________

Psychosis _______________________________________________________________

Dementia _______________________________________________________________

Alcohol/Substance Use ____________________________________________________

Physical Health Issues _____________________________________________________

________________________________________________________________________

Developmental and Social History

Place of Birth _______________________ Where were you raised? _________________

Please note any important information about the following events in your life:

Your mother's pregnancy with you____________________________________________

________________________________________________________________________

Did you begin walking at an appropriate age? Yes No

Did you begin talking at an appropriate age? Yes No

Did you toilet train at an appropriate age? Yes No

What's the earliest recollection you have? What was/is the feeling about this recollection? _____________________________________________________________

_______________________________________________________________________

What do you remember about starting school? __________________________________

________________________________________________________________________

What was puberty like for you? ______________________________________________

________________________________________________________________________

What was your role in high school (e.g., "leader," "follower," "loner," etc.)? __________

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What level of education have you attained (circle highest and list area of study, if applicable)?

GED Bachelor's Degree____________________

High School Diploma Some Graduate Studies________________

Some College Graduate Degree _____________________

Associate Degree______________ Doctoral Degree _____________________

Have you ever been arrested for any reason? Please list charge, dates, outcomes:

________________________________________________________________________

_________________________________________________________________________

Family History

List your siblings from oldest to youngest. Include yourself in the order. Use the back of this page if you require more room.

Name _____________________________ Current age ______________

While you were growing up did you experience any of the following trauma?

Neglect or abandonment Yes No

Emotional abuse Yes No

Physical abuse Yes No

Sexual abuse Yes No

Violence in your home Yes No

Divorce of parents Yes No

Crime Yes No

War Yes No

Spiritual History

Was your family of origin religious? Yes No

Did you attend religious services? Yes No

Did you ever feel abused by religion? Yes No

Of the following, which best describes the religion with which you grew up (Circle one)?

Buddhism Bahai

Hinduism Catholic Christianity

Jainism Protestant Christianity

Sikhism Orthodox Christianity

Islam Judaism

Taoism Atheism

Confucianism Paganism

Wicca Other__________________

Of the following, which best describes your current religious identification (Circle one)?

Buddhism Bahai

Hinduism Catholic Christianity

Jainism Protestant Christianity

Sikhism Orthodox Christianity

Islam Judaism

Taoism Atheism

Confucianism Paganism

Wicca Other _________________

Briefly describe the earliest religious/spiritual experience you can remember __________

________________________________________________________________________

________________________________________________________________________

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