test form GENERAL Name Date of birth Address City State ZIP Home Phone May I leave a message Yes No Work/Cell phone May I leave a message Yes No Email May I leave a message Yes No Employer / School Occupation Emergency Contact Phone Relationship Educational Background Learning disabilities Religious upbringing Present affiliation/identification (if any) Current living situation Reason for seeking counseling/therapy at this time What do you hope to achieve with therapy? Previous counseling (dates/names of therapists) Medical History General Health Are you now under a physician’s care? Yes No If yes, reason for care Physician's Name Telephone Medications Reason for medication Have you ever been hospitalized for a mental illness? Yes No Describe Have you ever considered or attempted suicide? Yes No If yes, please explain Have you ever been in a drug, alcohol or other treatment program? Yes No If yes, please provide details Do you currently drink alcohol? Yes No How much/how often Do you currently use recreational drugs? Yes No How much/how often Do you feel you have a problem with alcohol or drugs? Yes No FAMILY INFORMATION Significant partner status (please select) Single Engaged Married Divorced Separated Living together Remarried Widowed Name of significant partner If living together, how long? If married, how long? If previously married/partnered, please indicateName of former partner Years together Reason no longer together Children from current relationship 1. Name Gender Age 2. Name Gender Age 3. Name Gender Age 4. Name Gender Age Children from previous relationship 1. Name Gender Age 2. Name Gender Age 3. Name Gender Age 4. Name Gender Age Parents and step-parents (indicate under “age” if deceased) 1. First Name Age Education Marital Status Occupation 2. First Name Age Education Marital Status Occupation 3. First Name Age Education Marital Status Occupation 4. First Name Age Education Marital Status Occupation Siblings and step-siblings (indicate under “age” if deceased) 1. First Name Age Education Marital Status Occupation 2. First Name Age Education Marital Status Occupation 3. First Name Age Education Marital Status Occupation 4. First Name Age Education Marital Status Occupation