re: New Client Questionnaire (Confidential)

Protecting your privacy and health information is our highest priority. Please be assured that no information on this form will be shared without your express consent, and in accordance with HIPAA.

If you're a new client, please complete and submit this form prior to your first session. This form is confidential and will be encrypted and can only be read by Donna Kennedy.

Client Information

First name

Last name

Parent/Legal Guardian if Under 18

Include parent/legal guardian name(s) and phone numbers.

Referred By?

Marital Status

Never married Married Separated Domestic Partnership Divorced Widowed

Cell phone number

Home phone number

Date of birth

Email address

Street

Town/ State

Zipcode

What is your preferred primary method of contact?

Cell phone Text Email Home phone

May I leave you a message via:

Cell phone Home phone

How did you find/hear about re: therapy / Donna Kennedy?

If you were referred to me please include their name so I may thank them

Emergency Contact Information

First name

Last name

Relationship to you

Home phone number

Cell phone number

Email address

History

Mental Health History Have you received any type of mental health services?

Psychotherapy Psychiatry Alcohol or Substance Abuse Treatment Other None

If yes to any of the above, please provide name and specialty of provider

Start and End Dates of services (approximate is fine)

Please include any previous or current mental health diagnosis/diagnoses

Have you ever been prescribed any psychotropic medications?

Yes No

Are you currently taking any psychotropic medications? (anti-depressant, anti-anxiety, mood stabilizer, etc.)

Yes No

Prescriber Name and location

To provide the best care, it may become important that I am able to communicate and collaborate with your other healthcare providers. Will you sign a release for the same?

General Health Information

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

Yes No

If yes, please describe the reason for your visit

Date of your last physical exam

Is there a chance that you are pregnant?

Yes No

How would you rate your current physical health?

Poor Unsatisfactory Satisfactory Good Very good

How would you rate your sleeping habits?

Poor Unsatisfactory Satisfactory Good Very Good

Please list any specific sleep problems you are currently experiencing (too much/little, difficulty falling/staying asleep, not feeling well-rested, etc). How long have these problems persisted?

How many times per week do you generally exercise? What types of exercise do you usually participate in?

Please list any difficulties you experience with your appetite or any eating problems, past or present

Please describe/list your personal health/wellness goals:

Are you currently experiencing overwhelming sadness, grief or depression?

Yes No

If yes, for approximately how long?

Are you currently experiencing anxiety, panics attacks or have any phobias?

Yes No

If yes, when did you begin experiencing this?

Are you currently experiencing any chronic pain?

Yes No

If yes, please describe:

Do you drink alcohol more than once a week?

Yes No

Are you concerned that your drinking may be a problem?

Yes

How often do you engage in recreational drug use?

Daily Weekly Monthly Infrequently Never

Please specify substance and frequency

Are you currently in a romantic relationship?

Yes No

If yes, for how long?

Please list area(s) of concern, if applicable

Are you interested in couples or family therapy at this time?

Family Mental Health History

In the section below, identify if there is a family history of any of the following. If yes, please indicate the family member’s relationship to you in the space provided (e.g. father, grandmother, uncle, etc.)

Obesity

Yes No

Obsessive Compulsive Disorder

Yes No

Schizophrenia

Yes No

Suicide Attempts

Yes No

If yes to any of the above, please indicate which category and family member’s relationship to you in the space provided (e.g. father, grandmother, uncle, etc.)

Additional Information

Please indicate your current employment status

Full Time Part Time Unemployed Retired Temporarily Disabled Permanently Disabled

Do you consider yourself to be spiritual or religious?

Spiritual Religious Atheist Agnostic Unsure

If you are spiritual or religious, please describe your faith or belief:

What do you consider to be some of your strengths?

What do you consider to be some of your weaknesses?

What would you like to accomplish out of your time in therapy?

Signature

Signed

Type your full name

Today's date

Your information will be encrypted.

re: New Client Questionnaire (Confidential)

Protecting your privacy and health information is our highest priority. Please be assured that no information on this form will be shared without your express consent, and in accordance with HIPAA.

Client Information

Emergency Contact Information

History

General Health Information

Family Mental Health History

In the section below, identify if there is a family history of any of the following. If yes, please indicate the family member’s relationship to you in the space provided (e.g. father, grandmother, uncle, etc.)

Additional Information

Signature

Protecting your privacy and health information is our highest priority. Please be assured that no information on this form will be shared without your express consent, and in accordance with HIPAA.

Donna Kennedy, LCSW, LCADC

Psychotherapist, Clinical Director, donna@retherapyllc.com