Parenting Counseling Client Questionnaire & Record Please note: Information provided on this form and in session are protected as fully confidential information. Personal InformationName *DateParent/Legal Guardian (if under 18)EducationStudent/Working/ Home maker/RetiredCityStateMobile *May I leave a message?YesNoEmail *May I leave a message?YesNoDOBAgeGenderMarital Status:Never MarriedDomestic PartnershipMarriedSeparatedDivorcedWidowedReferred By (if any)HistoryHave you previously received any type of emotional or mental health services (psychotherapy, psychiatric or counseling services, etc.)?YesNoIf yes, previous therapy/practitionerAre you currently taking any prescription medication?YesNoIf yes, please listHave you ever been prescribed psychiatric medication?YesNoIf yes, please list and provide datesGeneral and Mental Health1. How would you rate your current physical health?PoorUnsatisfactorySatisfactoryGoodVery goodPlease list any specific health problems you are currently experiencing:2. How would you rate your current sleeping habits?PoorUnsatisfactorySatisfactoryGoodVery goodPlease list any specific sleep problems you are currently experiencing3. How many times per week do you engage in physical activity or exercise?What types of exercise do you participate in?4. Please list any difficulties you experience with your appetite or eating problems:5. Are you currently experiencing overwhelming sadness, grief or depression?YesNoIf yes, which and for approximately how long?6. Are you currently experiencing anxiety, panic attacks or have any phobias?YesNoIf yes, state which and when did you begin experiencing this?7. Are you currently experiencing any chronic pain?YesNoIf yes, please describe:8. Do you drink alcohol more than once a week?YesNo9. Do you engage in recreational drug use?DailyWeeklyMonthlyInfrequentlyNever10. What significant life changes or stressful events have you experienced recently?Family Mental Health HistoryIn the section below, identify if there is a family history of any of the following. If yes, please indicate the family member’s relationship to you in the space provided (e.g. father, grandmother, uncle, etc.).Alcohol/Substance Abuse Yes / NoYesNoAnxiety Yes / NoYesNoDepression Yes / NoYesNoDomestic Violence Yes / NoYesNoEating Disorders Yes / NoYesNoObesity Yes / NoYesNoObsessive Compulsive Behavior Yes / NoYesNoSchizophrenia Yes / NoYesNoSuicide Attempts Yes / NoYesNoAdditional Information1. What area of your life/relationships would you like to improve?2. What would you like to accomplish out of your time in therapy?Your NameSubmit
