Client Information Please tell me about yourself: Name:Age:DOB:Email Contact Information:Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country PhoneIs it ok to email you to confirm appointments?*YesNoReferral Source:Insurance Company:Insurance ID:Phone number on the back of insurance cardAre you the primary insured in the policy?If not, please list the name of the primary insuredRelationship Status:Years:Have you received counseling services in the past? If so, please list when and purpose:Please list any significant health problems you have now:Please list all medications (prescribed or over-the-counter) which you take:Have you ever been hospitalized for mental health reasons? If yes, when and why:Have you ever attempted suicide? If yes, when and how:Please mark any of the following, which are currently problems for you: Depression Fears Sleeping LGBT Issues Alcohol/Drug Use Eating problem Fearing Failure Stress Making decision Sexual problems Suicidal thoughts Anger Terminal illness Disturbing Thoughts Health Relationship Problems Death of loved one Self-esteem Panic Guilt Anxiety Memory/Concentration Perfectionism Obsession/Compulsion Legal Matters Other OtherWhat is your average weekly intake of alcoholic drinks per week?Any recent increase?At the time of your life when you were drinking the most, how much did you drink weekly?List any other kinds of drugs you sometimes use, or have used in the past, legal or illegal including frequency of use:Abuse/Trauma History:Please mark any that you have experienced personally or that have happened to others and have significantly impacted your family: Physical Abuse Sexual Abuse Emotional Abuse Witnessed Abuse Serious Illness/Injury Sudden death of a loved one Loss of home Loss of job Other OtherFamily & significant others:Mother (age/quality of your relationship)Father (age/quality of your relationship)Are they still married to each other?Your age when they split upSpouse/Partner (name & age):Sisters & Brothers (first name & age):Children (first name/age/other parent if different than current partner):Married Previously?How long were you married?When/why did relationship end?Has any biological family member ever had a drinking or drug problem, depression, nervous breakdown, mental disorder, or attempted suicide? Please describe:What is your goal for counseling (what do you want to be different in your life)?