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.