Client Info Form
Tracy Deagan and Associates Psychotherapy/ Violet Crown Counseling
Client Information
Name _________________________________ Date ___________________________
Email _________________________________________________________________
Address _______________________ Phone# ____________ Apt#: _______________
City ______________________ State _______________ Zip ____________________
Employer ____________________ Employer Phone# __________________________
Can we call at home? ______________ at work ? ______________________________
May we email you? ______________________________________________________
Birth Date _______________________ Age __________________________________
Single? ____ Partnered ? ____ Married ?___ Other?(please name) ________________
If current relationship , date this relationship began?
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Other family Members in home - name, age, & relationship
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Emergency contact person - name, phone, and relationship
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Please describe your reason for seeking counseling now. Have you been in counseling before?
Please indicate if you are now or have been in a relationship with abuse or neglect, as giver or reciever
Please tell us your primary care doctor and the medications you are currently on / substances you currently use
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Who may we thank for this referral ?
________________________________________
Do you presently use doctor prescribed medication ? if so list name, dosage, and doctor that ordered
__________________________________________________________________
Do you have any significant health problems? describe :
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Do you feel in crisis at present?
__________________________________________________________________
Please describe any past or present thoughts, attempts, or plans to hurt yourself or someone else
__________________________________________________________________
__________________________________________________________________
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Is there anything else we need to know to serve you better?
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