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Completed By:
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Today's Date:
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(mm/dd/yyyy)
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E-Mail:
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Date of Birth:
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(mm/dd/yyyy)
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Social Security Number:
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(nnn-nn-nnnn)
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Home Phone:
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(nnn-nnn-nnnn)
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Street Address:
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City:
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State:
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Zip Code:
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Employer:
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Occupation:
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Business Phone:
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Others living at home. Please include Gender, Age, Employer/School,
as applicable.
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Reason for seeking treatment.
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| Family of Origin: |
Describe what you know about your family: age of parents,
number of siblings, family dynamics, abuse and/or neglect, drug
and alcohol abuse, crime, adoption, etc.
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Describe your mother and father (positive and negative).
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How did your parents show affection to each other and their children?
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How did your parents handle disagreements and conflicts; what were
their main methods of discipline?
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How many siblings do you have and what role did each sibling play
in the family?
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Discuss history of alcohol or drug abuse; physical, emotional or
sexual abuse; mental or emotional illnesses in the family; how was each
issue dealt with?
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List the number of disruptions (moves away from a family) you experienced,
reason for each, length of time and age in each placement, and what degree
of abuse, neglect or nurturing you received in each placement.
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| About You: |
Describe your challenges and problems from childhood through adulthood.
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Describe your positive attributes.
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Describe previous therapy you have had, duration, and results.
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Describe your hopes for coming to Evergreen Psychotherapy Center.
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| Medical History: |
List any current/past illnesses/injuries that has impacted you or your
family. e.g. inner ear problems, colic, hospitalizations, premature birth,
lack of prenatal care, etc.
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| Marital/Relationship History: |
Describe your current marriage / relationship (positive and negative);
i.e. intimacy, communication, problem solving, togetherness.
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Write a brief description of any previous marriage(s) / relationship(s).
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| Current Family: |
List your children and give a brief description of each child.
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What are your main methods of discipline and how effective have they been?
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What concerns do you have with any other member of the family?
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How large of a role (if any) does religion play in your family?
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Describe positive attributes, strengths and support systems in your current
family?
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Credit Card (VISA/MC) Information:
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Name on Credit Card:
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VISA
MasterCard
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Credit Card Number:
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Expiration Date:
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CV (3 digits
on back of credit card):
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Street Address:
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City:
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State:
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Zip Code:
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Phone:
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E-mail:
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