Client Information Form
Date
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
D.O.B.
Address
Referred by
Gender identification
Sexual orientation identification
Racial identification
Ancestral identification (if known)
What is the highest grade in school, year in college, or post college education or training you have completed?
Describe briefly what brings you to therapy and what you would like to work with. What have you done to try to help the situation? Has anything helped?
What do you want to accomplish from the work we will do together?
Have you ever been in therapy before? How was it?
What are your hopes about therapy?
What are your fears about therapy?
If you identify as BIPOC, are you currently experiencing distress due to discrimination, or racialized trauma, that you would like support with in therapy?
If you identify as gender non-conforming, non-binary, or LGBTQI+, are you experiencing distress due to discrimination or related trauma, that you would like support with in therapy?
Who lives in your household (# of people/ages/relationships)? Are you happy with this arrangement?
How would you describe your circle of friends?
Are you currently in a primary relationship? If so, for how long? Briefly describe the quality of the relationship.
Please describe the strategies you most often use for coping with stress.
Do you have any history of addiction or alcohol/substance abuse? What is your present use?
Do you have any history of sexual abuse? Please describe briefly, including the extent to which you have had the opportunity thus far to do any healing around it.
Have you had experiences with altered states of consciousness? This could include meditation, spiritual practice, wilderness experience, guided indigenous healing modalities, and psychedelics, whether ceremonial or recreational. If yes, how have these experiences impacted your life?
Is there any history of addiction/alcoholism, sexual or physical abuse, or mental illness in your family?
Have you ever had any thoughts about suicide? Have you ever attempted suicide? Please explain, including if you are currently experiencing these.
Please list any significant (to you) accidents, surgeries, and hospitalizations with date.
Please describe briefly your spiritual practices/beliefs, if any.
Do you consider yourself to be a creative person? How do you express your creativity?
Have you ever feared that being yourself authentically would result in rejection by those closest to you? Or, by peers? If so, what aspects of yourself remain unknown to others that you wish they could see?
How is your physical health? How is your sleep?
How do you feel about how you eat?
What is your daily caffeine intake?
Please describe your perception of your relationship to nature.
What kinds of exercise do you get, and how often?
Can you describe briefly your memories of playing as a child?
What do you do for fun now? What inspires and brings you joy or excitement?
Please list any other health care practitioners you are currently working with.
Please list any medications, supplements, homeopathy, herbs etc. you are currently taking.
What else should I know about you at this time?
Email
example@example.com
Thank you for sharing this information. It will be held in confidence.
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