Client Registration and Information Form

THE INTEGRAL PSYCHOLOGY CENTER
Full Name
First Name Last Name
Date
People you presently live with
Person #1
Relationship
Age
Occupation
Person #2
Relationship
Age
Occupation
Person #3
Relationship
Age
Occupation
Person #4
Relationship
Age
Occuaption
Marital History
1. Name of Spouse
Years Married
# of Children
Reason if Separated
2. Name of Spouse
Years Married
# of Children
Reason if Separated
3. Name of Spouse
Years Married
# of Children
Reason if Separated
Educational History
Highest Grade Completed
Degress
Other Education
Any Difficulties

YesNo
Physical Health
Name of Physician
Date of Last Visit
Do you take any prescribed medication (please list)
Any major health problems or physical/sensory disabilities? (please list)
Do you exercise regularly (if so ,what do you do?)
Do you use: Caffeine?

Yes No
Do you use: Alcohol?

Yes No
Do you use: Tobacco?

Yes No
Mental Health History
If you or a family member have been to a therapist before, please indicate who, when and why:
In your family, has there ever been an incident of:
Suicide of suicide attempts?

Yes No
Incest of sexual molestation?

Yes No
Child abuse?

Yes No
Serious harm to or by another person?

Yes No
Major life changes within the past year?

Yes No
Which of the following items are of concern to you:
Please check

Depression Mood Swings Suicidal Feelings or Thoughts Anxiety, Fears, Worries Irritable, Angry, Hostile Feelings Self- Esteem Loneliness Lack of Assertiveness/ Shyness Eating/Weight Problems Alcohol and/or Drugs Smoking Loss of a Significant Person Physical Symptoms (e.g., headaches, pain) Compulsive Behavior Romantic Relationship Sexual Matters Family Problems Conflict with Others Gay/Lesbian Issues Pregnancy Career/Work Issues Chronic of Life Threatening Condition Emotional, Physical or Sexual Abuse Other Loss or Change
Other, please specify
Please complete the following
The reason I am seeking therapy now is
What I want most from my therapist is
I will know my therapy has been successful when
Other things that my therapist should be aware of are:
If we need to confirm or cancel an appointment, may we telephone you at
home

Yes No
work

Yes No
Should be Empty:

Client Registration and Information Form

People you presently live with

Marital History

Educational History

Physical Health

Mental Health History

Which of the following items are of concern to you:

Please complete the following