| MURRAY S KAUFMAN, MA.LMFT,NBCDCH Marriage and Family Counseling Clinical Hypnotherapy 1. Name:______________________ 2. Address: ___________________________ 3. City: _______________________ 4. State: _____ 5. Zip_____________ 6.Home Phone ___________________ 7. Work Phone__________________ 8. Cell Phone_____________________ 9. Email: _________________________ 10. Fax: ____________________ 11.Date of Birth: _________12. Age_________ 13. Gender___________________ 14. Religion_______________ 15. Ethnicity___________________ 16.Marital Status:______ 17. (#)Children___________ 18. Occupation: __________________If student, part-time /full-time: ___________________ 19. Employer: ___________________________ 20. Address:___________________________20A. City__________20B.State:_________ 21. How did you hear about this practice? A. Referral Source_________________Address____________________________ Phone_______________ B. Specify Internet Site _________________________ 22. Main Purpose For This Consultation: Please give a brief summary of the main problems:____________________________________________________ ___________________________________________________________________ ___________________________________________________________________ 23. Why Are You Seeking An Evaluation At This Time? What are your goals for Counseling/Therapy? _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ ___________________________________________________________________________ 24. Any prior psychiatric, counseling/therapy history? Y or N ( If yes please explain): _________________________________________________________________________ ______________________________________________________________________ ___________________________________________________________________________ 25. Were these treatments helpful? Please describe: _________________________ ___________________________________________________________________________ Medical History 1. Current Medical Problems/Disabilities: __________________________________________________________________________ _________________________________________________________________________ 2. Current Medications/ supplements/vitamins/herbs: __________________________________________________________________________ 3. Past medical problems/Previous Medications: ______________________________________________________________________ _______________________________________________________________________
__________________________________________________________________________ 5. Have you ever injured your head, had a concussion or played football? Y or N If yes, please explain:____________________________________________________________ 6. Any seizures or seizure-like activity?____________ 7. Prior abnormal lab tests? X-rays, EEG, MRI: _________________________________________________________________________ 8. Any allergies? Y or N (If yes, please list) __________________________________________________________________________ 9. Prior medical-related hospitalizations? ( Place, Cause, Date, Outcome) ________________________________________________________________________ __________________________________________________________________________ 10. Have you ever been hospitalized for an emotional issue? Y or N If yes, please describe (place, date, cause, outcome): __________________________________________________________________________ __________________________________________________________________________ 11. Were any members in your family of origin ever diagnosed with an emotional disorder? ____, Y or N (if so, what, and your age at the time) ___________ __________________________________________________________________________ 12. Current Life Stress (include anything that is currently stressful for you, i.e relationship(s), job, school, finances, children): __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ 13. On a scale of 1-10; ( 1 being the least, and 10 being the most, what do you feel is your current level of stress: ___________. 14. What result would you like to see from your therapy?_____________________________ __________________________________________________________________________ 15. In case of emergency, whom may we contact? Name: ________________________ Relationship:_______________________________ Address: ______________________ City:_________________ State:____________ Zip:_____________ Phone: __________________________. Irvine Counseling and Hypnosis 714-418-7454 or Email |
Please print and complete this Initial Client Form, and bring with you to your first appointment.
