Confidential Client Information Form

One Life Counseling, LLC Jonathan Douglass,LPC,LCADC

You only have one life, live it well NJ licence: 37PC0054400 + 37LC00264200

Date

Name

Address

Ok to send mail

Yes No

Date of Birth

Email address

Phone Number

Ok to receive calls/messages

Yes No

Emergency Contact Name & Number

Sex

Sexual orientation

Ethnicity

Disability status

Partner(s)/relationship:

Occupation/Employer:

Who referred you to me or how did you hear of my practice?

Current reason(s) for seeking therapy:

Estimate the severity of the problem for which you are seeking care:

Mild Moderate Severe

Have you ever been hospitalized? (If yes, please provide details):

Are you currently taking any medications? (Please list names, dosages, and prescribing doctor.):

Have you previously been in psychotherapy? When and for what issues?

Was it helpful? (Why or why not?)

Do you have any previous suicide attempts, self-destructive behaviors, or violent behaviors? (Indicate age, circumstances, and whether it led to hospitalization or legal problems).

Please list any past/present drug and alcohol use. What have you used and how much? What are you currently using and how much? Has it ever affected your work or your relationships?

Do you live with others? What is their relationship to you?

Present Spouse/Partner(s) (first name(s), occupation(s), how would you describe your relationship satisfaction?):

Are there any other current relationships that are a significant focus in your life right now? Please describe:

What are your main worries or fears?

What do you consider your main strengths?

What are your primary challenges right now?

What are your most important hopes or dreams?

Please add any additional information that may be helpful to our work together.

Your information will be encrypted.