16300 Mill Creek Blvd, #207, Mill Creek, WA 98012

16300 Mill Creek Blvd, #207, Mill Creek, WA 98012

Deborah Mauldin, LICSW 425) 877-9808

16300 Mill Creek Blvd, #207, Mill Creek, WA 98012

CONFIDENTIAL CLIENT INFORMATION

ABOUT YOU:

Name ______Today’s Date ______

first middle last

Birthdate ______Age ______Sex: Male _____ Female _____

Address ______Home Phone ( ) ______

City ______Zip ______Cell ( ) ______

Email ______

Emergency Contact ______Phone ( ) ______

Employed by ______Occupation ______

Work Hours ______Business Phone ( ) ______

Do you enjoy work? Is there anything stressful about your current work?

Do you consider yourself spiritual or religious? □ No □ Yes Please describe your faith or belief:

What would you like to see as an outcome of therapy?

FAMILY INFORMATION:

Marital Status □ Never Married □ Married □ Domestic Partnership □ Separated □ Divorced □ Widowed

Spouse or Significant Other ______

Birthdate ______Age ______Occupation ______

Employed by ______Business Phone ( )______

Please list any children/ages

What significant life changes or stressful events have you experienced in the past 12 months?

□ Divorce/separation □ Job Change/Financial changes □ Change in relationship with child or partner

□ Death of family member or friend □ Traumatic event □ Serious illness or injury of self or family

Other ______

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Deborah Mauldin, LICSW 425) 877-9808

16300 Mill Creek Blvd, #207, Mill Creek, WA 98012

GENERAL HEALTH AND MENTAL HEALTH INFORMATION

Primary Physician ______Phone # ______Last visit ______

How would you rate you current physical health?

Poor UnsatisfactorySatisfactoryGoodVery Good

Are you currently experiencing any chronic pain? □ No □ Yes

If yes, please describe?

Please list any health problems you are currently experiencing and/or medical history I should be aware of:

Please list any prescription and non prescription medications you are currently taking

PrescriptionNon prescription and supplements

Are you experiencing sadness, depression, self-harm or suicidal thoughts?□ No □ Yes

If yes, please describe and for how long:

Are you experiencing anxiety, racing thoughts, phobias, or panic attacks? □ No □ Yes

If yes, please describe and for how long:

Have you experienced any changes in the following?

Sleep NightmaresSexual DriveWeightAppetiteEnergy Level

Please describe:

How many times per week do you generally exercise?

What types of exercise do you participate in?

How often do you drink alcohol?

□ Never □ Infrequently □ Monthly □ Weekly □ Daily

How often do you engage in recreational drug use?

□ Never □ Infrequently □ Monthly □ Weekly □ Daily

Have you wanted/needed to cut down on alcohol or drug use in the last year? □ No □ Yes

Are family members or friends concerned about your alcohol or recreational drug use? □ No □ Yes

If yes, please tell me more?

Please list names of prior mental health therapists and psychiatrists. Please include approximate dates you saw them, for what reason, how long treatment lasted, and the outcome.