Client Information Form | Louis Carlino, MA, LPC

Client Information

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Name(Required)

First Last

Preferred Name(Required)

Birthdate(Required)

Phone(Required)

Email(Required)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Occupation

Educational Level:

Emergency Contact Information

Emergency Contact Name

First Last

Emergency Contact Phone

Your relationship to Emergency Contact

Medical Information

MD Name

First Last

MD Phone

Psychiatrist Name

First Last

Psychiatrist Phone

Medical Problems/Prescribed Medications:

Personal Information

Leave blank any items you do not feel comfortable answering

Gender Identification

Ethnic/Cultural Identification:

Sexual Orientation:

Relationship Status:

Religious/Spiritual Affiliation:

Do you have children?

What are your childrens age(s)

Background Information

Briefly describe your reason(s) for seeking therapy at this time:

What are your goals for therapy?

Briefly describe any major losses or traumas:

Have you been in therapy before?

Please briefly describe your therapy:

Have you ever attempted suicide?

When did you attempt suicide?

Have you ever been hospitalized for mental health issues?

When were you hospitalized for mental health issues?

Please briefly describe your current use of alcohol/recreational drugs

Previous use of alcohol/recreational drugs:

Does your family have any history of mental illness, suicide, substance abuse, trauma, or abuse? If so, please describe briefly:

Any other comments?

Date