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Client Information Form 3 Cut & Paste


The Happiness Psychologist

W F Diak III, PhD

31790 US 19N 50

Palm Harbor, FL 34684

(727) 280-6569

License #: PY 8129



Client Information Form

This form asks you some preliminary questions that assist me in determining how I can best help you. Some of the questions may seem unusual, or may not apply to your situation. However, it is important that I ask these questions in the interest of obtaining a thorough initial assessment of your situation. The more I know about you the more successful I can be in helping you attain your counseling goals. Please complete the form to the best of your ability.

Name: Address:

City: State: Zip:

Daytime Landline Phone: Okay to leave messages for scheduling? Y N

Evening Landline Phone: Okay to leave messages for scheduling? Y N

Cell Phone: Email: Date of Birth: Age: Gender: M F

Height: Weight: Race/Ethnicity: Marital/Relationship Status:

Social Security Number: - - Driver's License Number:

Household (please include adult children & children not living with you):

Name Age Relationship

Emergency Contact Information:

Name: Relationship: Phone:

Highest educational level attained:

Degree: Date: School: GPA:

Other degrees, certifications, licenses:

Current occupation: Length of time at this occupation: Employer:

Counseling Goals

What has led you to seek counseling at this time?

Do you want to improve a specific area of your life?

Are you facing a specific challenge or problem? Y N Describe:

When did this begin?

How have you been coping with this challenge or problem?

Are there other areas of your life that you would like to improve? Y N Describe:

How would you like counseling to help you?

What are some of your specific goals for counseling?

Do you want to improve your life in general? Y N

Do you have any other concerns?

What would be your ideal result from counseling?

Did someone suggest that you seek counseling? Y N Who?

Mental Health

What is your current mood? Please explain:

Have you ever had any unusual perceptual experiences such as:

Hearing voices when no one was actually present?

Hearing noises without any apparent source?

Seeing people or objects that were not actually present?

Perceiving unusual smells?

Feeling that someone or something was touching you, when nothing was?

Have you ever experienced an unusual amount of energy that allowed you to stay awake much longer than usual & accomplish many activities? Y N When?

Have you ever had a period of time when you engaged in risky behavior, excessive shopping, risky gambling, or other behavior that was not typical for you? Y N When?

Do you feel suicidal? Y N Have you ever felt suicidal? Y N How recently?

Do you intend to harm yourself? Y N Have you ever attempted to harm yourself? Y N


Have you ever threatened to harm anyone? Y N Describe:

Is there anyone that you want to harm? Y N Describe:

Do you have any firearms or weapons in your home? Y N

Ever received counseling, psychotherapy, or psychiatric care? Y N

Provider name: Dates:

For what issue(s) did you go to get help?

What was the outcome?

Have you ever been hospitalized for psychiatric reasons? Y N When?


Do you have any history of experiencing physical abuse, sexual abuse, or sexual assault? Y N


Drugs, Alcohol, Substances

List all drugs (including medications), herbal, & other supplements you use with dosage, & frequency:

List all psychiatric medications that you use:

List all drugs or supplements you recently stopped taking, & when:

Do you have any history of alcohol, drug, or substance abuse? Y N Describe:

Physical Health

Who is your primary physician? When was your last medical check up?

How is your health in general?

Do you have any serious or chronic illnesses? Y N Please list:

Have you ever had a head injury (concussion)? Y N When? Describe:

Have you had any other noteworthy injuries? Y N When? Describe:

Do you have any physical disabilities? Y N Please list:

Do you have any eating concerns? Y N Problems with sleep? Y N


Do you have any other health concerns that you'd like to share with me? Y N



Do you have any current or anticipated involvement with the legal system? Y N

Have you ever been involved in litigation? Y N Describe:

Have you ever been arrested? Y N If so, what were the charges?


Where did you learn of my services?

Thank you for taking the time to complete this information form. Your answers will to help you to get the most out of your counseling experience!