New Client Questionnaire (Adult)

Emergency Assistance

If this is an emergency, call:

Client Information

First name

Last name

Preferred Name

Date of birth

Street Address

Street

City

State

State & Zip Code

Cell Phone Number

Secondary phone number

Can we send appointment reminders by text?

Yes No

Email Address

If applicable, please complete the following: partner's name, children's names and ages, other people currently residing in your residence

ReWritten Counseling does not complete requests for disability as a part of our standard services.

I acknowledge and understand

Counselors reserve the right to temporarily pause sessions with a client when an unpaid balance reaches $100. Once balance is paid in full sessions can resume.

I acknowledge and understand

Insurance Information

Primary Insurance:

Please enter (none) if you have no health insurance

Policy Holder Name:

Employer:

Policy/Member Number:

Please enter (none) if you have no health insurance

Policy Holder SSN:

Policy Holder Date of Birth:

Do you have a secondary insurance policy?

Yes No

Secondary Insurance:

Policy Holder Name:

Policy/Member Number:

Policy Holder Date of Birth:

Emergency Contact Information

Add second emergency contact

Preferred Appointment Type

In Person

Telehealth

Medical History

Have you been treated by a doctor in the last 12 months?

Yes No

If yes, please describe the reason for your visit and any diagnosed medical conditions that would impact your treatment:

Date of your last physical exam

Please list the medications you are taking and for what conditions. Include the dosage and amounts.

Do you have any allergies to medications?

Current Symptoms

In your own words, describe the current problems as you see them:

How long has this been going on?

What made you come in at this time?

What do you hope to gain from counseling services?

If you have had difficulties in the past, what have you done to cope? Was it helpful?

List any current or past life experiences that impact your current symptoms (i.e. past trauma, death in family, job loss, etc.):

Please describe any other symptoms or experiences you have had problems with:

Treatment History

Have you seen a counselor, psychologist, psychiatrist or other mental health professional before? Have you been hospitalized for psychiatric reasons?

Yes No

If so, please list name of therapist or hospital, reason for seeking help, and dates of treatment:

Do you use alcohol?

Yes No

If so, how would you describe your use?

Minimal Moderate Heavy

Do you currently or have you in the past used recreational drugs?

Yes No

If so, describe current or past use and any past treatment for substance use:

Family and Social History

Has anyone in your family been diagnosed with a mental health disorder or substance abuse issue?

Yes No

If so, describe family relationship and diagnosis or symptoms:

Are you currently employed or a student?

Yes No

Describe your employment or social activities (i.e. hobbies, religious affiliations, etc.):

Is there any other information not listed above that you would like your therapist to know?

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