General Info Form

I. BASIC INFORMATION

Hidden

Type

Individual
Couples
Mediation

Today's Date

Name

Birthday

Age

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Cell Phone

Work Phone

Prefer to be called on which number?

Email

Who (other than children) lives at this address? Give names & relationship. Can a message be left with them? Y / N

Employer

Occupation

Business Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Work Hours

Education (highest level completed)

Are you currently in school?

Yes
No

What are you studying?

Degrees

Source of Referral: Who referred you to me?

II. FAMILY INFORMATION

A. Family:

Mother Alive?

Yes
No

Year Mother Died

Mother's Birth Place

Father Alive?

Yes
No

Year Father Died

Father's Birth Place

Parent's Live together?

Yes
No

Siblings: Names/Ages:

Do any family members have a history of psychological problems?

Yes
No

If so, please describe

Do any family members have a history of medical problems?

Yes
No

If so, please describe

B. Information About CHILDREN

List Name of each Child ,M/F, Date of Birth, Age, Grade Level, Where Resides

(Use new line for each child)

Are there any speciﬁc health/educational/mental health requirements for any of these children? For Whom? What?

III. PERSONAL INFORMATION

How long have you been in relationship (in years if applicable)

Partner's Name

If there are unusual circumstances relevant to your relationship, please describe:

Have you been hospitalized for medical reasons?

Yes
No

Describe medical reasons

Have you been hospitalized for psychological reasons?

Yes
No

Describe psychological reasons

Have you ever had any physical or mental illness, signiﬁcant health problem or serious accidents that affected you for an extended period of time (more than a year)?

Yes
No

If so, please indicate type/ dates/ and current status.

Your health in childhood was generally:

Excellent
Good
Fair
Poor

At present your health is generally:

Excellent
Good
Fair
Poor

When was your last physical?

How often do you exercise?

How often do you meditate?

List medications (including vitamins, aspirin, sleeping pills, etc.) during last 2 years:

If you are currently in any type of therapy or counseling, what kind?

With whom are you in therapy or counseling?

For how long?

Will you give me written permission to speak to your current therapist?

Yes
No

Have you had any history of physical or sexual abuse?

Yes
No

By Whom?

Have you needed to cut back on drinking or drug use?

Yes
No

If so, when?

What substance(s)?

IV. FINANCIAL INFORMATION

Pre-Covid19, what was your approximate Gross income?

Net income?

Current Approximate Gross?

Current Net?

Partner's Net?

Changes in income in the last two years?

Yes
No

And, or expected in next 2 years?

Yes
No

Please explain

Financial concerns you have i should know about?

V. MAJOR LIFE EVENTS or CHANGES

Check all that apply

VI. Emergency Contact:

Emergency Contact Name

Emergency Contact Email

Emergency Contact Cell Phone

Emergency Contact Relationship to you

Insurance Company Name

Who's name is your insurance under?

Yours
Your partners

Isnsurance Phone #

Member #

VII. Your Thoughts:

Please describe brieﬂy why you are seeking professional help? Why now?

What concern(s) do you have for yourself?

For others?

Anything else I should know?

Comments? Questions?

During Covid. Zoom Sessions Only.

JOY A. DRYER Ph.D

General Registration