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New Client Information Form

To begin services with Tim O'Brien, LPC, please fill out this online form, when you press submit, your form information will be sent to Tim O'Brien and you will be sent an email with our contact information. If you are unable to fill out this form, it will be provided to you at the first appointment.

* indicates required field
*Full Name Date of Birth
(mm/dd/yyyy)
Address
City State Zip
*Home Phone OK to leave message
Work/Cell Phone OK to leave message
*Email
By whom were you referred
Guardian's Name (if you are a minor)
Marital Status
Partner's Name
Emergency contact person
Emergency contact phone
Insurance Company
Insurance Policy Number


EDUCATION
Currently enrolled in school?
Total number of years completed/degree
Current school
Teacher
Phone


EMPLOYMENT
Currently employed?
Employer
Occupation
Job responsibilities and stress level of job


LEGAL
Involved in any legal activities (civil, criminal, custody, probation, etc.)?
If yes, please describe
Traffic Violations (DUII/DWI)? Civil/custody lawsuits?


MENTAL HEALTH TREATMENT
Participated in counseling before?
If so, with whom?
Reason for treatment
Concerns
(Please check the behaviors and symptoms that occur more often than you would like)
Aggression Alcohol use Angry outbursts Argue/conflicts
Anxiety Computer use Confused thoughts Depression
Delusions Disorientation Disorganized thoughts Distractability
Dizziness Drug use Eating Elevated mood
Fatigue Gambling Hallucinations Hopelessness
Impulsivity Irritability Judgement errors Loneliness
Memory impairment Mood swings Panic attacks Phobias/fears
Racing thoughts Reoccuring thoughts Self-harm Sexual addiction
Sexual difficulties Smoking Spending money Sleeping problems
Social isolation Suicidal thoughts Worrying
Briefly describe how the above checked symptoms impair your ability to function effectively
Presenting Problems
Please describe what brings you to us
What do you hope to gain from therapy?
What do you do to help cope or feel better
Have you ever had thoughts about hurting yourself or someone else?
If yes, please describe
Have you purposely hurt yourself or another?
If yes, please describe


FAMILY HISTORY
Please indicate any significant family history


MEDICAL INFORMATION
Current physician
Phone
Physician's Address
Date of most recent complete physical examination
(Do you have a history of any of the following conditions?)
Serious accident Head injury High fevers
Vision problems Digestion problems Abortion
Cancer Seizures Surgery
Meningitis Hearing problems Asthma
High blood pressure Diabetes Chronic pain
Heart problems Allergies Hospitalization
Headaches Loss of consciousness Pregnancy/miscarriage
Speech/language problems Sexually transmitted disease Thyroid problems
Tuberculosis Hepatitis A/B/C/D/E/G Fibromyalgia
Anemia/blood problems Immune deficiencies Significant wieght gain/loss
Other:
List medications
List allergies or adverse reactions to medications
Do you smoke? Amount/How often
Drink alcohol? Type & Amount
Use illegal drugs? Substances & Amounts
Do you exercise regularly? Amount & How
 Daily intake of caffeine


Check here to sign the form. This affirms that information you submit is current and correct.

Information will be forwarded to
.
© 2008 Tim O'Brien, LPC. All rights reserved.
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