Shifaa Integrative Counseling
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Client Information Form
Please provide the following information using the below online form.
You can leave blank any of the non-required questions that you would rather not answer.
Information you provide here is held to the same standards of confidentiality as your therapy sessions.
Please fill out and submit this form prior to your first session.
Once you submit it, it will be sent securely and kept confidential.
Background Information
*
Indicates required field
Name
*
First
Last
Email
*
Phone Number
*
Birthdate
*
Gender
*
Male
Female
Marital Status
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Select
Married
Partnered
Never Married
Divorced
Separated
Widowed
Number of years Married
*
Are you currently receiving psychiatric services, professional counseling or psychotherapy elsewhere?
*
Yes
No
If Yes, please provide the name and contact of your therapist
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Have you had previous counseling?
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Yes
No
Are you currently taking prescribed psychiatric medication (antidepressants or others)?
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Yes
No
If Yes, please list:
*
Health and Social Information
How is your physical health at present?
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Poor
Unsatisfactory
Satisfactory
Good
Very good
Are you having any problems with your sleep habits?
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Yes
No
If Yes, check where applicable:
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Sleeping too little
Sleeping too much
Poor quality sleep
Disturbing dreams
other
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How often do you exercise?
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Never
Rarely
once a month
once a week
3 times a week or more
Are you having any difficulty with appetite or eating habits?
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Yes
No
If Yes, check where applicable:
*
Eating less
Eating more
Binging
Restricting
Do you use alcohol?
*
Select
Yes
No
Sometimes
Never
In a typical month, how often do you have 4 or more drinks in a 24-hour period?
*
Select
Never
Rarely
3 or less
Often
How often do you engage in recreational drug use?
*
Select
Daily
Weekly
Monthly
Never
Have you had suicidal thoughts recently?
*
Select
Frequently
Sometimes
Rarely
Never
Have you had suicidal thoughts in the past?
*
Select
Frequently
Sometimes
Rarely
Never
In the last year, have you experienced any significant life changes or stressors?
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Have you ever experienced (select all that apply):
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Extreme depressed mood
Wild mood swings
Rapid speech
Extreme anxiety
Panic attacks
Phobias
Hallucinations
Unexplained losses of time
Unexplained memory lapses
Alcohol/substance abuse
Frequent body complaints
Eating disorder
Body image problems
Repetitive thoughts (e.g.: obsessions)
Repetitive behaviors (e.g.: frequent checking, hand washing)
Homicidal thoughts
Suicide attempt
In your family, has anyone ever had conflicts resulting in pushing, shoving, hitting or breaking things?
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Yes
No
If Yes, please explain:
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Has anyone in your family experienced difficulties with the following? (check all that apply)
*
Depression
Bipolar disorder
Anxiety disorders
Panic attacks
Schizophrenia
Alcohol/substance abuse
Eating disorders
Learning disabilities
Trauma history
Suicide attempts
Additional Information
Do you consider yourself to be religious?
*
Select
Yes
No
Sort of
If Yes, what is your faith?
*
Do you consider yourself to be spiritual?
*
Select
Yes
No
Sort of
What do you consider to be your strengths?
*
What do you like most about yourself?
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What are some effective coping strategies that you've learned?
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What are your goals for therapy?
*
Submit
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