Counseling New Client Assessment Orchard Hill CounselingNew Client AssessmentAll information provided will be held in confidentiality. Personal Information Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Preferred Phone * (###) ### #### May we leave a voicemail? * Yes No What is your preferred contact method regarding appointments? * Text Email Do you have any specific instructions regarding communications? Occupation Birthday * MM DD YYYY Gender * Male Female Self Identify If self-identify, indicate below. Education Highest grade or degree completed How would you describe life in your family of origin? Healthy/Stable Unhealthy/Unstable Did your parents remain together? Yes No If not, what age were you when they were separated or divorced? Emergency Contact Name First Name Last Name Relationship Phone (###) ### #### Email Current Concerns What is your reason for seeking counseling and/or what are your current concerns? Have you received therapy/counseling for these or other concerns? Yes No If yes, please describe previous counseling experiences. What are your goals counseling? List your personal strengths. Who are your primary supports? Health Information Current Physical Health Rating Very Good Good Average Declining Poor List any current physical conditions, illnesses, or injuries. List any previous physical conditions, illnesses, or injuries. Average hours of sleep per night. 3-6 hours 6-9 hours 10+ hours Any significant (10+ lbs) weight gain or loss over the pass month? Yes No If yes, please explain. Do you have any history of head injury? Yes No If yes, please explain when and the outcome. Current Mental Health Rating Very Good Good Average Declining Poor Have you ever been diagnosed with an eating disorder? Yes No Have you ever been treated for drug or alcohol abuse or dependence? Yes No If yes, date/outcome. Have you ever been treated for anxiety or depression? Yes No If yes, date/outcome. Any current suicidal ideation? Yes No If yes, please explain. Have you attempted suicide in the past? Yes No If yes, note when. Any current/past self-injury? Yes No If yes, note how long since your last episode. Have you ever been hospitalized for psychiatric reasons? Yes No If yes, date/outcome. Have you ever received any other mental health diagnosis? Yes No If yes, which one? In the case of an emergency, please list any medications you currently take and your purpose for taking them. Relationships and Sexual Information Sexual Orientation Heterosexual Homosexual Bisexual Uncertain Other If other, please explain. Is sexual orientation a concern for you? Yes No Any concerns regarding your past sexual history or current sexuality? Any past history of intimate partner abuse? Yes No If yes, please explain. Relationship Status Single Cohabiting Married Separated Divorced Widowed If currently separated, divorced, or widowed, how long? If currently married or in a relationship: Name of Partner First Name Last Name Time Together Ages when married? Provide both the husband and wife. How long did you know your spouse before marriage? Do you have any present concerns about your marriage/relationship? Have you had previous marriages? Yes No If yes, please explain when and how long. For parents, please answer the following questions about your children. For women, how many pregnancies have you had? Have you or your spouse/partner had a miscarriage? Yes No Unknown If yes, when? Have you or your spouse/partner had an abortion? Yes No Unknown If yes, when? Have you experienced the death of a child? Yes No If yes, when? Please list provide the following information about your children. Full name, age, sex, and marital status. Spiritual Information Do you attend church? Yes No If yes, is your home church Orchard Hill? Yes No Have there been any notable changes in your spiritual life? Yes No If yes, please explain. Would you like spirituality incorporated into counseling? Yes No Is there anything else you would like your counselor to know about you that was not asked on this initial assessment? Thank you!
