Marriage and Individual Counseling Form Marriage and Individual Counseling Form Personal Information Today's Date * First Appointment Date * Name Name First First Last Last Address * Address Address Address City City State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province Zip/Postal Zip/Postal Phone * Email * Emergency Contact * Emergency Contact First First Last Last Emergency Contact Phone * Do we have permission to contact you regarding follow-up appointments? Yes No Age Birth Date Prior to today, have you been to our office? Yes No If yes, when? How did you hear about us? Yellow Pages Poster Physician Name Church/Pastor Friend/Relative Internet Radio Other (Please specify)Other (Please specify) Race African American Caucasian Hispanic/Latin American Asian/Pacific East Indian Native American Marital Status Divorced Married Single Widowed Separated Occupation Title Income Level 0-$14,000 $15,000-29,000 $30,000-44,000 $44,000-59,000 $60,000-100,000 OVER 100,000 Rate your health Very Good Good Average Poor Declining Other, Please explainOther, Please explain Have you had any recent weight changes? Yes No Approx. weight loss Approx. weight gain How do you sleep at night? Sleep soundly all night Can’t get to sleep Fall asleep, but awaken after several hours & can’t go back to sleep List all important present or past illnesses, injuries, or handicaps: Date of last medical examination: Report Your Physician Your Physician First First Last Last Are you presently taking prescribed medication? Yes No Have you used drugs other than for medical purposes? Yes No If yes, please list below along with how long you have been taking each: Have you ever had psychotherapy or counseling before? * Yes No If yes, please list name of therapist or counselor: If yes, please list name of therapist or counselor: First First Last Last Date of last visit: If you are human, leave this field blank. Next
