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Client Info Form

Tracy Deagan and Associates Psychotherapy/ Violet Crown Counseling

Client Information

Name _________________________________ Date ___________________________

Email _________________________________________________________________

Address _______________________ Phone# ____________ Apt#: _______________

City ______________________ State _______________ Zip ____________________

Employer ____________________ Employer Phone# __________________________

Can we call at home? ______________ at work ? ______________________________

May we email you? ______________________________________________________


Birth Date _______________________ Age __________________________________


Single? ____ Partnered ? ____ Married ?___ Other?(please name) ________________


If current relationship , date this relationship began?

______________________________________________________________________


Other family Members in home - name, age, & relationship

 ______________________________________________________________________

Emergency contact person - name, phone, and relationship

 ______________________________________________________________________


Please describe your reason for seeking counseling now. Have you been in counseling before?



Please indicate if you are now or have been in a relationship with abuse or neglect, as giver or reciever



Please tell us your primary care doctor and the medications you are currently on / substances you currently use

______________________________________________________________________


Who may we thank for this referral ?

 ________________________________________


Do you presently use doctor prescribed medication ? if so list name, dosage, and doctor that ordered

__________________________________________________________________


Do you have any significant health problems? describe :

__________________________________________________________________


Do you feel in crisis at present?

__________________________________________________________________


Please describe any past or present thoughts, attempts, or plans to hurt yourself or someone else

__________________________________________________________________

 __________________________________________________________________

__________________________________________________________________


Is there anything else we need to know to serve you better?

_____________________________________________________________

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