BACKGROUND & INFORMATION – Adult
Client #: __________ Reviewed: _________
DATE: ___________________________ Updated: 3/26/04
INSTRUCTIONS: This confidential information form is for your therapist's use in getting to know you
better. Please complete all information as carefully and accurately as you can.
PERSONAL INFORMATION
Full Name _________________________________________________________________
Leave Other
At the following phone #’s, is it OK to Call? Message? Instructions
Home phone: (____)___________________ Y N Y N ____________________
Work phone: (____) ___________ X ____ Y N Y N ____________________
Cell/pager: (____)___________________ Y N Y N ____________________
Address ___________________________________________________________________
City ____________________________ State _____________________ Zip _________
SS#: _____-____-______ Birth date ____/____/____ Age ________ Sex: M F
Referred by ______________________________________________________________
Address __________________________________________________________________
City __________________ State _________ Zip _______ Phone (____)___________
If Internet, which website? AAMFT _____ Other __________________________
If Yellow Pages, which directory? Large Indianapolis _____ Northside _____
What helped you choose this therapist? __________________________________
_________________________________________________________________________
Marital Status (check)
Single ______ Cohabiting ______ Engaged ______ Married ______
Separated _______ Divorced ______ Widowed ______
If currently married
How many years married? ________ Age when married? ________
Have either of you ever considered divorce? Yes _____ No _____
Who _____________ Reason? ____________________________________________
Filed for divorce? Yes _____ No _____
Who _____________ Date _________ Reason? ___________________________
Does your spouse know you are in therapy? Yes _____ No _____
Is you spouse willing to come to therapy? Yes _____ No _____ ? _____
If previously married
#1) Dates of marriage ____________________________ Years married __________
Children? Yes ____ No ____ How many? _______ (indicate below w/”1st”)
#2) Dates of marriage ____________________________ Years married __________
Children? Yes ____ No ____ How many? _______ (indicate below w/”2nd”)
Children
___________________________________________________________________________
Name Age Father/ Sex Adopted? Step- Living Marital
Mother child?__w/you?__Status?
| | / M F Y N Y N Y N S M W D
| | / M F Y N Y N Y N S M W D
| | / M F Y N Y N Y N S M W D
| | / M F Y N Y N Y N S M W D
| | / M F Y N Y N Y N S M W D
| | / M F Y N Y N Y N S M W D
| | / M__F____Y__N____Y__N_____Y__N___S_M_W_D
Religion
Religion __________________ Denomination _________________________________
Church attendance per month (circle one) 0 1 2 3 4 5+
Do you consider yourself a spiritual person? Yes _____ No _____ ? _____
Do you believe in God? Yes _____ No _____ Uncertain _____
Explain any significant events or changes in your spiritual life (past or present) __________________________________________________________________
__________________________________________________________________
__________________________________________________________________
EDUCATION INFORMATION
(circle last Grade School 1 2 3 4 5 6
year completed) Jr/High School 7 8 9 10 11 12
College 1 2 3 4 5 6+
Diplomas/Degrees earned: ______________________________ Date __________
_______________________________________ Date _____________
_______________________________________ Date _____________
Other training: Type __________________________________ # Yrs ___________
Type __________________________________ # Yrs ____________
OCCUPATION INFORMATION
Present Employer
Employer ____________________________________ Phone (____)____________
Address ____________________________________________________________
City ____________________________ State ___________________ Zip _________
Position _____________________________________ # of years _________________
How satisfied are you with your job/career? _______________________________
Please explain __________________________________________________________
_____________________________________________________________________
Insurance (circle)
Do you have health insurance? Yes No Through: Self Spouse Parents
Insured’s name: ________________________ SS#:____-___-_____ DOB:___/___/___
Insurance company: _____________________ Employer: ________________________
Group/Policy #: ______________ Phone #’s: (___)__________/(___)____________
Income
What is your approximate family income (including your spouse)?
29,999 or below _______ 30,000 - 59,999 _______ 60,000 - 99,999 _______
100,000 - 149,999 _______ 150,000 - 199,999 _______ 200,000 or above ______
Military History
Have you ever served in the military? Yes ______ No ______
If yes, branch of service: ___________________ # of Years _____________
Are you a foreign war veteran? Yes ______ No ______
If yes, which war: ________________________ Dates _____________________
HEALTH INFORMATION
Rate your health: Very Good ______ Good ______ Fair ______ Poor _______
Approximate weight: ______ lbs Amount recently: Lost _____ Gained _____
List any important past or present illnesses or injuries, and their cause:
___________________________________________________ Dates _________________
___________________________________________________ Dates _________________
___________________________________________________ Dates _________________
List any handicaps: ______________________________________________________
Physician ___________________________________ Phone (____)________________
Address ___________________________________________________________________
City ____________________________ State ___________________ Zip _________
Date of last medical examination: ________________________________________
Are you currently taking any medication(s)? Yes _______ No _______
If yes, list the medication and its purpose:
_________________________ Purpose _______________________________________
_________________________ Purpose _______________________________________
_________________________ Purpose _______________________________________
_________________________ Purpose _______________________________________
