4Thought Counseling, LLC

6470 East Johns Crossing, Suite 160 Johns Creek, GA 30097

Today’s Date:_____/______/______
CLIENT INFORMATION SHEET

Name _______________________________________________ Date of birth _____/_____/_____

Age_____________

Client Social Security #: ______________Sex: Male/ Female Race/Ethnicity (optional) __________

Marital Status: Single Married Separated Divorced

Address ____________________________________________________________
City/State/Zip _________________________________________ Home Phone ______________
Email Address__________________________________________ Cell/Work Phone ___________
Occupation _________________________________Employers Name: _______________
Name of your Primary Care Physician ________________________________________________
PCP Phone: ______________________ PCP Fax________________________________________
Referred By: ____________________________
May I contact or leave messages for the client or parent/Legal Guardian at the numbers listed
above? Yes / No
If Client is under age 18 Please provide the Name of Parent/Legal Guardian Bringing Child to
Appointment:
_________________________________________________________________________________
Insurance Information
Insurance Company Name: _______________
Phone # for Mental Health Benefits/Services: _________________
Policyholder’s Name: _______________________ Date of Birth: ____ /____/____ Sex: M / F
Policyholder’s Address: ___________________________________________________________
Policyholder’s SSN: ______________________ Marital Status: ____________________
Member ID Number/Medicaid#: ________________________________
Group/Plan/Policy#_____________________
Authorization for services may be required prior to treatment. Did you obtain authorization for services
from your insurance company? Yes/No /Not required Authorization #: ____________# of sessions
approved ___
Policyholders’ Employer (Name & Address)
________________________________________________________________
Other people living in the home:
Name Age Relationship to Client
_________________________________________________________________________________
________________________________________________________________________________
_________________________________________________________________________________
Emergency Contact: _______________________________________
Relationship_________________________________
Complete Address: _________________________________________________________
Home Phone: ______________Work Phone: _____________________ Cell Phone: _____________
Spouse’s Name (If not Emergency Contact): _________________________________________
Home Phone: _____________________Work Phone:_____________ Cell__________
Phone:_________________________
 PATIENT SELF REPORT

Patient Name: ______________________________Age:__________ Date: ________________________

Name of person completing this form (if not patient):

______________________________________________________

1. Briefly describe the problem which brought you here

today._______________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

2. Check any issues you are having difficulty with.

ADHD Depression Anxiety Relationship

hyperactive sad excessive worry marital/significant other

impulsive sleep problems panic attacks parenting

under achievement neg. thinking irrational fear difficulty with friends
non-compliant poor concentration obsessions work/school problems
inattentive hopeless/worthless social isolation personal growth
poor concentration mood swings phobias grief/loss
disorganized guilt compulsive bullying/teasing

Anger Addictions Abuse Other

short-fused alcohol physical agitated
temp. tantrums drugs emotional mania
impulse control gambling domestic violence paranoia
violent/assaultive relationships/sex rape delusions
runaway risk eating disorders sexual tics/tourette's
fighting cyber/internet dissociative cutting behavior
irritable spending nightmare/flashback oppositional
appetite changes
eating disorders pregnancy
loss abortion

3. Are you now or have you ever had thoughts of hurting yourself
or someone else? yes no

Past Treatment
4. Have you ever been treated for psychiatric, substance abuse, emotional, or behavioral
problems in the past? yes no

5. If yes, when, where, and with whom? ____________________________________

Inpatient____________________ Outpatient ________________________________ counselor
psychologist psychiatrist substance abuse counselor
6. Did you find past treatment helpful? yes no

if yes, how'? __________________________________________________________ if

no, why not? ________________________________________________________

7. Please list any medications given: _______________________________________

____________________________________________________________________

8. Are you currently under the care of a psychiatrist or therapist for your current
problem? yes no

9. Are you currently taking any medications for psychiatric problems? yes no
If yes, please list: ______________________________________________________
____________________________________________________________________

Medical Problems
10. Do you have any current medical problems? yes no
If yes, please list: ____________________________________________________

11. When was the last time you were seen by a doctor? ______________________
12. Would you like information from today’s visit communicate with your medical doctor?
yes no

13. Are you currently taking medication for

medical problems? yes no
lf yes, please list medication, dosage, and purpose: __________________________
___________________________________________________________________

14. Do you have any allergies and/or medication allergies? yes no

If yes, please list: ____________________________________________________

15. Do you have a history of head injury, seizures or

loss of consciousness? yes no
Please explain: ______________________________________________________

16. (Women only) Are you pregnant? yes no

17. Do you have pain management issues? yes no

Substance Abuse
18. Have you been treated for drug, alcohol abuse, or other addictions (food,
gambling, sex)? yes no

19. Do you currently attend support groups? yes no

20. Circle the following you have used in the past 30 days: tobacco,
alcohol, rnarijuar1a, tranquilizers, sleeping pills, pain killers, heroin,
cocaine/crack, amphetamines/speed, methadone, LSD, PCP, ecstasy, inhalants.
2l. Have you experienced withdrawal symptoms? yes no
If yes, circle all which apply: withdrawal, headaches, nausea, vomiting,
tremors, seeing things, hearing things.

22. Have you ever been arrested for a DUI? yes no

Legal Issues
23. Do you have current legal problems? yes no
If yes, describe: ______________________________________________________
___________________________________________________________________

24. Are you currently on probation/parole? yes no

25. Do you haves DFACS worker? yes no

Employment/Education
26. Circle current employrnent status; full time, part time, unemployed,
homemaker, student, disabled, retired.

27. Are you currently on leave from work

or seeking medical leave/disability? yes no
lf yes, do have paperwork that needs to be completed? yes lf no
yes, please give clinician paperwork at beginning of session!

28. Circle educational background:. current student, did not complete high
school, graduated high school, GED, some college, graduated college,
advanced degree.

29. Did you experience difficulties in school? yes no

Family/Relationships

30. Please list anyone who lives in your home, his/her age, and relationship,
___________________________________________________________________
___________________________________________________________________

31. Does anyone in your immediate family have-psychiatric, emotional,

substance abuse, or behavioral problems? yes no

32. ls your immediate family supportive of you seeking treatment? yes no

33. Does anyone in your extended family have psychiatric, emotional,

substance abuse, or behavioral problems? yes no
lf yes, please describe: ________________________________________________

34. Do you have any domestic violence history or current issues? yes no

35. Do you have any history of sexual and/or physical abuse? yes no
36. Is your support network (Circle one) Good? Fair? Poor?
(i.e. friends, family, neighbors, religious organizations)
Please list: __________________________________________________________

37. What are your hobbies/interests? _____________________________________

___________________________________________________________________

38. Do you have difficulties or concerns about how you get

along with other people? yes no ·

39. Are you having difficulties with spiritual or religious matters? yes no

40. Do you have any sexual orientation/gender issues or concerns? yes no

Treatment Access/Mobility
41. Are there any financial concerns that would affect your ability
to access treatment'? yes no

42. Do you have access to transportation? yes no `·

43. Do you have any disabilities, special needs, or other restrictions

that may impact your treatment or access to treatment? yes no

44. Based on the information you provided in this self report, what would you like to see
changed? ___________________________________________________
___________________________________________________________________
____________________________________________________________________

45. In your opinion, what could block or prevent that change? __________________
____________________________________________________________________
____________________________________________________________________

_______________________________________________________
_________________________________
Patient (or person completing this form) signature Date

_______________________________________________________
__________________________________
Clinician Signature/Credentials Date