Adult Registration Form

Dee Dee, Co-Therapist

Date

Form Completed By:

Name

Age

Date Of Birth

Height

Weight

Current physical health problems/diagnoses

Past physical health problems/diagnoses

Current medications for physical health

Current mental health diagnoses

Past mental health diagnoses

Current medications for mental health problems

Do you have any disabilities that you know of?

Profession

Place of employment

Home Town and State

Level of Education

Currently in school? If so, where?

Primary Support System Information

Please write the names, and relationship (to client)

Describe your spiritual belief system.

Others living at home

Please provide the name, sex, and age of others residing in the home.

What therapies do you currently undergo?

What therapies and/or hospitalizations have you undergone before?

Please describe areas of concern for which you are seeking treatment

Do you smoke?

Yes No

How much?

Do you drink?

Yes No

How much?

Do you use street drugs of any kind?

Yes No

What street drugs do you use and what is the frequency and dosage?

Do you use over-the-counter medications?

Yes No

What are your hobbies and interests?

Please describe areas of concern for which you are seeking help:

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