Client Information Form
Sign in to Google to save your progress. Learn more
Email *
Name (and preferred, if different)
Address (Street, City, State, Zip)
Phone Number *
Emergency Contact  - Please list name, relation, and phone number of someone who will NOT be in session with you. 
Date of Birth
MM
/
DD
/
YYYY
Age
Gender
Primary reason for beginning therapy?
Have you attended therapy before? 
If yes, please list with whom, dates, issues addressed, and if you found it helpful. 
Occupation
Birthplace *
Marital Status
length of relationship, if applicable
Relationship Satisfaction *
extremely unsatisfied
extremely satisfied
Have any of the following been present in your current relationship
Have you ever experienced any of the following (not including in your current relationship)
Partner's first name
Partner's age
partner's occupation
partner's personality (strengths and weaknesses)
Any other important relationship information?
please list other household members and ages:
(example)
Jennifer, sister, 42
Ryan, son, 8
Lucy, daughter, 7
Max, goldendoodle, 12

 *
Check all that apply about your Mother *
Required
Check all that apply about your Father *
Required
If your parents divorced, how old were you at their divorce?
Please list siblings and their age in relation to yours, as well as any other important people who lived with you
example:

Beth, sister, 7 years older
Ben, brother, 2 years younger
Carl, step dad
Cathy, step sister, 9 years older
Tim, half brother (dad) 1 years younger
Grandma, took care of me from ages 7-10
 *
ACEs Screen

Please select all options that apply to you ("yes") before your 18th birthday
 *
Required
Do you have suicidal thoughts and/or have you attempted suicide in the past? (if yes, what was your plan or action?) *
Substance Use *
Never
Sometimes
Often
In the past, but no longer use
Alcohol
Nicotine
Marijuana
Cocaine/Stimulants
Hallucinogens
Sedatives
Methampetamines
other non-prescription drug use
Has anyone ever said your use of the above is a problem? *
Current medications *
Mental Health and Family History *
yes (please describe below)
no
Have you ever been hospitalized for a psychiatric illness?
Has a close relative ever been hospitalized for a psychiatic illness?
Has anyone in your family attempted suicide?
Did anyone in your family have problematic mental health symptoms
Have you ever been arrested?
Have you served in war/combat?
additional information to my "yes" answers above:
*
1: cannot function
2
3
4: moderate issues
5
6: mild issues
7
8
9
10: no problems
How well are you doing at your job/school
How well are you doing in your romatic relationship?
How well are you doing in your family relationships?
How are you doing in relationships with people outside your family?
Rate your current physical health
Rate your general well being
Other symptoms and/or therapeutic goals (top 5-8) *
Required
which of the above (or other) causes you the most distress
Anything else you'd like your therapist to know (optional):
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Springs Therapy. Report Abuse
Google Forms