HEALTH REPORT

Current physical issues:                                Medications being taken :

___________________________            ______________________________________________________

___________________________            ______________________________________________________

___________________________            ______________________________________________________            ___________________________            ______________________________________________________

___________________________            ______________________________________________________

         Presenting issues:                        Duration (months):                         Additional Information:    

_______________________          ___________________            _______________________________

_______________________          ___________________            _______________________________

_______________________          ___________________            _______________________________

 

Have you received treatment/therapy in the past? ____  With whom: ______________ How Long: ______

 

Did you feel helped? _______  Why? ______________________________________________________

 

What are you hoping to gain from counseling at FCCS? ________________________________________

_____________________________________________________________________________________

 

 How were you referred to FCCS? _________________________________________________________

Freedom Christian Counseling Services

Client Information Sheet

Date  ____/____/____    

CLIENT  INFORMATION

 

 

  All information on this sheet is strictly confidential unless client requests otherwise or required by law.

PRESENTING ISSSUES

 

Name ____________________________________________      Age_____      Date of Birth ____/____/____

 

Address _________________________________________________________________________________

 

Phone # at which you would like to be reached:  _______________     _____________     ______________

 

E-mail Address __________________________             Your occupation: _________________________

 

Marital Status: ___________      Years married:  ___________           Prior marriages: ________________

 

 

            List persons living in your household:                              What is their relationship to you:

           _______________________________                              ______________________________

           _______________________________                              ______________________________

           _______________________________                              ______________________________

           _______________________________                              ______________________________

           _______________________________                              ______________________________

           _______________________________                              ______________________________