CALL ME : 1-443-253-1660

Linda S. Crites, Ph.D.
LINDA S. CRITES, Ph.D.
Individual Psychotherapy and Family Counseling
(443) 253-1660
Client Information Form Today’s date: _________________
A. Identification
Your name: ____________________________________________ Date of birth: __________________ Age: _____
Home street address: ________________________________________________________ Apt.: ________________
City: ___________________________________________________________ State: _____ Zip: _______________
Preferred phone: ______________________________ e-mail: ____________________________________________
Social Security #: ________________________________________________________________________________
Calls or e-mail will be discreet, but please indicate any restrictions: _________________________________________
B. Referral: Who gave you my name?
Name: ________________________________________________________ Phone: ___________________________
Address: ________________________________________________________________________________________
May I have your permission to thank this person for the referral? ❑ Yes ❑ No
How can I help you? _______________________________________________________________________________
________________________________________________________________________________________________
C. Religious and racial/ethnic identification
❑ Protestant ❑ Catholic ❑ Jewish ❑ Islamic ❑ Buddhist ❑ Hindu Other (specify): ________________
How important are spiritual concerns in your life? _________________________________________________________
Ethnicity, national origin, Race or other way you identify yourself and consider important: _________________________
D. Your medical care: From whom or where do you get your medical care?
Clinic/doctor’s name: ____________________________________________ Phone: ____________________________
Address: __________________________________________________________________________________________
If you enter treatment with me, may I tell your medical doctor so that he or she can be fully informed we can coordinate your treatment? ❑ Yes ❑ No
E. Your current employer
Employer: ________________________________________ Address: ___________________________________________
Work phone: _____________________________ Preferred means of communication _____________________________
F. Emergency information
If an emergency arises and we cannot reach you directly, or we need to reach someone close to you, whom should we call?
Name: __________________________________ Phone: ____________________ Relationship: ________________
Address: _______________________________________________________________________________________
G. Your education and training (post high school if over 18):
Dates School Problems Degree
____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
H. Employment and military experience:
Dates Name of employer Job title or duties Reason for leaving
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
I. Family-of-origin history
Relative Name Living/Deceased Current age Illnesses (or cause Education Occupation
(or age at death) of death, if deceased)
Father_________________________________________________________________________________________________
Mother________________________________________________________________________________________________
Brothers _______________________________________________________________________________________________
Sisters ________________________________________________________________________________________________
Stepparents ____________________________________________________________________________________________
-ther Important Family ____________________________________________________________________________________
J. Marital/partner relationship history
Date Partner’s name/age Status of Relationship
First ___________________________________________________________________________________________
Second ___________________________________________________________________________________________
Third ___________________________________________________________________________________________
K. Children
Name Age Sex School/Occupation Problems?
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
L. Any other information you think I should know (continue on back)?
This is a strictly confidential patient medical record. Redisclosure or transfer is expressly prohibited by law.