Client Information 

 

Name: 

etc

Religious Preference

Briefly Describe Your Reasons for Seeking Help:

 

 

Marital History: 

Never married

1st marriage: Date(s)___ Spouse___ Children___

2nd marriage: 

3rd marriage:

Who has custody of your minor children?

 

 

Have you ever considered suicide? 

Attempted?

 

Circle any of the following which are currently causing you difficulty: 

Anger

My Past

Anxiety

Nightmares

Phobia

Assertiveness

Addiction

Divorce

Self-Control

Cutting

Health

Dating

Sexual Prob.

Panic Attacks

Grief

Suicidal Thoughts

Parents

Hearing Voices

Depression

Obsessiveness

Career Choices

Self-Concept

Marriage

Concentration

Work

Energy

Sleep Trouble

Guilt

Step-Family

Legal Issues

Parenting

Food

Religion

Finances

Headaches

Abuse

Violence

Sadness

In-Laws

Hopelessness

Name *
Name