CONFIDENTIAL CLIENT INFORMATION

Elizabeth Herbert, LICSW 206-817-8904

18402-103rd St. NE, Bothell, WA 98011
Name ________________________________________
first

middle

Todays Date ____________________

last

Birthdate ___________________

Age ____________

Sex: Male _____ Female _____

Address _______________________________________

Primary Phone (

City ____________________

Cell (

Zip ________________

Email _________________________________________

) ________________

) _______________________

Emergency Contact _________________

Employer:

_______________________
Employed by ___________________________________
Work Phone (

Occupation ______________________

) _______________________________

How may I contact you: Primary phone No Yes

Work phone No Yes

Email No Yes

*Please note: Email correspondence is not considered to be a confidential medium of communication.

Emergency Contact:______________________________Relationship:
Do you enjoy work? Is there anything stressful about your current work? Work Hours:________________
______________________________________________________________________________________
Do you consider yourself spiritual or religious? No Yes

Please describe your faith or belief:

______________________________________________________________________________________
What would you like to see as an outcome of therapy?

FAMILY INFORMATION:
Marital Status Never Married Married Domestic Partnership Separated Divorced Widowed
Spouse or Significant Other ________________________
Birthdate ___________________

Age ____________

Employed by ___________________________________

Occupation ______________________
Business Phone (

)_______________

Please list any children/age ________________________________________________________________

Recent deaths of family or friends ? _______________________________________________________
What significant life changes or stressful events have you experienced in the past 12 months?
Divorce/separation
Legal Issues

Job change/Financial changes

Death of family member or friend

Change in relationship with child or partner

Serious illness or injury of self or family member

new child in family

1

Other __________________________________________________________________________________

Elizabeth Herbert, LICSW

18402-103rd St. NE, Bothell, WA 98011

FAMILY MENTAL HEALTH HISTORY:

In the section below identify if there is a family history of any of the following. If yes, please indicate the
family members relationship to you in the space provided.
Please circle

List Family Member

(Father, Mother, brother, etc).

Alcohol/Substance Abuse
Anxiety
Depression
Domestic Violence
Eating Disorders
Obesity
Obsessive Compulsive Behavior
Schizophrenia
Suicide Attempts

Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No

GENERAL HEALTH AND MENTAL HEALTH INFORMATION:

Primary Physician __________________________

Phone # _________________ Last visit ___________

How would you rate you current physical health?

Poor

Unsatisfactory

Satisfactory

Are you currently experiencing any chronic pain?

Good

Very Good

No Yes

If yes, please describe? ______________________________________________________________

Please list any health problems you are currently experiencing and/or medical history
_________________________________________________________________________________________
_________________________________________________________________________________________
__
_________________________________________________________________________________________
_
Please list any prescription and non prescription medications you are currently taking
Prescription

Non prescription and supplements

Elizabeth Herbert, LICSW

18402-103rd St. NE, Bothell, WA 98011

Have you experienced any changes in the following?

Sleep

Nightmares

Sexual Drive

Weight

Appetite

Energy Level

How would you rate your sleep habits?

Poor

Unsatisfactory

Satisfactory

Good

Very Good

Please list any specific sleep problems you are currently experiencing _______________________________
How many times per week do you generally exercise? _________________
What types of exercise do you participate in? ___________________________________________________
How often do you drink alcohol?
Never

Infrequently

Monthly

Weekly

Daily

Weekly

Daily

How often do you engage in recreational drug use?

Never

Infrequently

Monthly

Have you wanted/needed to cut down on alcohol or drug use in the last year? No Yes
Are family members or friends concerned about your alcohol or recreational drug use? No Yes
Please list names of prior mental health therapists and psychiatrists. Please include approximate dates you saw
them, for what reason, how long treatment lasted, and the outcome.
What do you consider to be some of your strengths?
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
____
What do you consider to be some of your weaknesses?
_________________________________________________________________________________________
_________________________________________________________________________________________
__

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_