Client Registration Form & Wellness Assessment

Emergency Assistance

If this is an emergency, call:

LA County Dept of Mental Health: (800) 854-7771
Los Angeles Crisis Text Line: Text "LA" to 741741
National Suicide Prevention Lifeline: (800) 273-8255
911
988

Client Information

First Name

Last Name

Date of Birth

Gender

Marital Status

Contact Information

Phone Number

Alternate Phone

Email Address

Street Address

City

State/Zip

What is your preferred method of communication?

Phone

Voicemail

Primary Care Physician

Phone Number

May we contact your primary care physician?

Yes No

Referred By:

Client Employer Information

Employer Name

Employer Phone

Employer Address

City

State/Zip

Client Occupation

Insured Person (if not client)

Name

Phone

Street Address

City

State/Zip

Subscriber ID #

Rel

Date of Birth

SSN

Insurance

Primary Insurance Company

ID #

Group #

Phone

Secondary Insurance Company

ID #

Group #

Phone

Emergency Contact

Add another emergency contact

In case of an emergency, do we have permissions to contact this person?

Yes No

Personal History & Wellness Assessment

Have you previously received therapy?

Yes No

If yes, what is the therapist's name?

Have you previously been prescribed psychiatric medication?

Yes No

If yes, what medications are you currently taking?

Do you have any pre-existing medical conditions?

This month, how many days have you missed work/school?

This month, have you been annoyed by people criticizing your drinking/drug use?

Yes No

Is there anything else regarding your family history that we should be aware of?

Do you use recreational drugs?

Regularly Occasionally No

Do you smoke?

Regularly Occasionally No

Do you drink alcohol?

Regularly Occasionally No

Do you drink caffeine?

Regularly Occasionally No

In the past week, how much did the following problems bother you?

Nervousness or shakiness

Not at all

A little

Somewhat

A lot

Feeling sad or blue

Not at all

A little

Somewhat

A lot

Feelings of hopelessness

Not at all

A little

Somewhat

A lot

Feeling everything is an effort

Not at all

A little

Somewhat

A lot

Feeling no interest in things

Not at all

A little

Somewhat

A lot

Heart pounding or racing

Not at all

A little

Somewhat

A lot

Trouble sleeping

Not at all

A little

Somewhat

A lot

Feeling fearful or afraid

Not at all

A little

Somewhat

A lot

Difficulty at home

Not at all

A little

Somewhat

A lot

Difficulty socially

Not at all

A little

Somewhat

A lot

Difficulty at work/school

Not at all

A little

Somewhat

A lot

How much do you agree with the following?

I feel good about myself

Strongly agree

Agree

Disagree

Strongly disagree

I can deal with my problems

Strongly agree

Agree

Disagree

Strongly disagree

I am accomplishing things

Strongly agree

Agree

Disagree

Strongly disagree

I have friends/family I count on

Strongly agree

Agree

Disagree

Strongly disagree

How many alcoholic beverages this week?

Current Symptoms

What do you hope to address in therapy?

Is there anything else you would like to add?

Your information will be encrypted.

Client Registration Form & Wellness Assessment

Emergency Assistance

Client Information

Contact Information

Client Employer Information

Insured Person (if not client)

Insurance

Emergency Contact

Personal History & Wellness Assessment

Current Symptoms

Emergency Assistance

Zain Psychological & Behavioral Services