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 ______

1 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 Unsatisfactory Satisfactory Good Very 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 Prescription Non 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 Nightmares Sexual Drive Weight Appetite Energy 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.