Christian life counseling, llc

Please return this form to:
Christian Life Counseling, LLC.
Located in the Eastbrook Park Office
Building E
12630 W. North Avenue
Brookfield, WI 53005
Fax: 262.432.9059
Phone: 262.785.1008
POLICY HOLDER OF INSURANCE ________________________ DOB ___________ WHO IS FINANCIALLY RESPONSIBLE ____________________________________ HOW WHERE YOU REFERRED? _________________________________________ EMERGENCY CONTACT __________________________________ PHONE # _________________________ RELATIONSHIP TO YOU _______________________________ SIGNATURE _______________________________ DATE _________________ SUMMARY OF CIRCUMSTANCES THAT BRINGS YOU TO CHRISTIAN LIFE COUNSELING___________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ PREVIOUS THERAPIST/DATES/REASONS FOR PRIOR THERAPY ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ MEDICAL HISTORY
NAME AND DATE OF ANY OPERATIONS AND/OR HOSPITALIZATIONS ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ SERIOUS ILLNESSES ____________________________________________________ ________________________________________________________________________ ________________________________________________________________________ SERIOUS INJURIES OR ACCIDENTS ______________________________________ ________________________________________________________________________ ________________________________________________________________________ ARE YOU CURRENTLY TAKING ANY OF THE FOLLOWING MEDICATIONS? PLEASE INCLUDE NAME AND DOSAGE. FAMILY HISTORY
PREVIOUS MARRIAGES: FROM___________TO_____________ PERSONAL HISTORY
How many cups: Coffee _____ Tea ______ Soda _____ How much per: Day _____ Week _____ Month______ Other chemicals/illegal drugs? _____________________________ YES NO Do you awaken in the middle of the night? Do you awaken in the morning without apparent reason? Have you experienced a change in appetite? Have you lost or gained weight in the last year? Are you currently having thoughts of suicide? Please explain: __________________________________ _______________________________________________ _______________________________________________ Have you had previous suicide thoughts and/or attempts in the past? YES NO Please explain: ______________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ Hospitalized for mental health (list dates and reasons) ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ SIGNATURE ______________________________

Source: http://www.christianlifecounseling.net/clc/files/2013_1-clc-adultintake.pdf