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.