New Client Registration & Health History Form - Shrink Inc. with Susan Thompson, LSCSW

Client Information

Name*

Address

Date of Birth

Email*

Employer

Home Phone

Work Phone

Cell Phone

Preferred way to contact:

Email
Home Phone
Work Phone
Cell Phone

Referred to me by:

Emergency Contact

Emergency Contact Phone

Is client a minor?

Yes
No

Responsible Party (if client is a minor)

Parent Name

Spouse Name

Address (if different than above)

Home Phone

Work Phone

Cell Phone

Parent Name

Spouse Name

Address (if different than above)

Home Phone

Work Phone

Cell Phone

Health History

Allergies

Psychiatrist or treating Dr.

Current Medications. Include name, dose (mg) and times/day:

Check each of the substances below that you currently use:

Caffeine (Coffee)
Caffeine (Tea)
Caffeine (Soft Drinks)
Alcohol (Beer)
Alcohol (Mixed Drinks/Neat)
Marijuana
Stimulants (Cocaine, Methamphetamine, etc)
Other Drugs
Cigarettes, Cigars, Chew Tobacco, Snuff

Please indicate the amount of Caffeine (Coffee) consumed per day:

Please indicate the amount of Caffeine (Tea) consumed per day:

Please indicate the amount of Caffeine (Soft Drinks) consumed per day:

Please indicate the amount of Alcohol (Beer) consumed, as well as if this number is per day, week or month:

Please indicate the amount of Alcohol (Mixed Drinks/Neat) consumed, as well as if this number is per day, week or month:

Please indicate the amount of Marijuana consumed, as well as if this number is per day, week or month:

Please indicate the amount of Stimulants consumed, as well as if this number is per day, week or month:

Please indicate the type, frequency, and amount of Other Drugs consumed.

Have you ever received treatment for additions? When/Where

Please indicate the amount of Cigarettes, Cigars, Chew Tobacco, Snuff consumed, as well as if this number is per day, week or month:

Check each of the boxes that applies to you:

I have suffered a fall or accident where I hit my head
I have suffered a concussion, closed head injury or other head injury
I have played football or another contact sport
I have lost consciousness
I have used inhalants, or been exposed to toxic materials

Provide detailed explanations of any boxes checked:

Hospitalizations or Surgeries (age and reason):

Check each of the symptoms you have suffered within the last 6 months:

Describe your sleep problems:

Describe the other physical problems you are concerned about:

Have you experienced any of the following?

Sexual abuse, assault
Physical abuse, domestic violence, assault
Accidents, incidents that were traumatic
Witnessed a traumatic event

Please indicate the age at which you experienced any of the above traumas:

Check each of the conditions below if you are currently suffering from them:

Diabetes
Heart Problems
Asthma
Bipolar
Depression
Thyroid
Addictions
Learning Disabilities

List your heart problems:

List your thyroid problems:

List your addictions:

List your learning disabilities: