New Client Information Form

Fields marked with an * are required

Welcome. This document is intended to quickly cover background information so that you can spend your first session sharing your current situation. Simply add the information to this document and return it. It should be emailed to me 24 hours in advance of our first appointment.

Please give the questions some thought however, it need not be longer than 2 pages. If there are gaps in the information, or additional pieces that you want to share, please remember to bring them up when you see me in person.

First Name

Last Name

Birthdate

Home Address

Phone

Description of the family you grew up in. i.e. names of parents, siblings, relatives that lived in your home, or held significant space in your home, sibling order and age differences.

Explain the worst and best parts of growing up in your family.

List serious illnesses both physical and mental that occurred in your family, and who had them.

Brief explanation of your education/career background.

Describe your current or recently significant relationship.

Pregnancies that were terminated or incomplete and adoptions (both maternal and your own).