Client History Form Complete this form to begin the information gathering process in preparation for your first meeting. Thank you and God bless! Name(Required) First Last Email(Required) Phone(Required)Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Who is your counselor?(Required)Choose Counselor HereDoug HerebicJosiah RileyKate HaasOther or UnknownChoose from the dropdown menu of which counselor you will be working with.Why are you seeking help now?(Required)What is happening or is different? What stressors or symptoms do you have? What do you hope will change by seeking help?Please give more details about the issue you named above:(Required)When did it start? How often does it happen? How does it affect your life? How have you dealt with it so far?Have you ever experienced similar symptoms before?(Required)If so, what was your experience like? When did it happen? Did you get help?Has anyone in your family ever experienced similar issues or mental health or substance use issues of any kind?(Required)If so, who was it? Did they seek help or get a diagnosis? What was it like for them? What was it like for you?Are you currently prescribed any medications?(Required)If so, please list the name, dosage, how often you take it, and the prescriber for each medication.Do you have any current or prior medical issues?(Required)If so, what was/is it? Have you seen a doctor or other healthcare professional for it? What recommendations or treatment did you have? Is there any family history of disease?Do you now, or have you ever, used alcohol, tobacco, recreational drugs, or prescription medication other than as prescribed?(Required)If so, which? When did you start, how often did/do you use, and how long did this occur? Please list each substance separately.Who is in your family? What is your relationship with them like?(Required)Please list all individuals you consider to be a part of your immediate family both in upbringing and currently. For those who are not part of your family of origin (such as significant others), please include the duration of your relationship.What spiritual practices and cultural influences are important to you?(Required)Do you belong to a particular religion, faith, denomination or spiritual community? What other cultural groups do you identify with?What social activities, hobbies, and relationships do you engage in?(Required)What important social relationships do you have? Do you belong to any social clubs, churches, or organizations? How do you like to spend your leisure time? Do you have any hobbies?What significant educational and work/volunteer experiences have you had?(Required)What is the highest level of education you have completed? Are you currently employed? If so, where and for how long? What other work and educational experiences have you had (such as a stay-at-home parent or semester abroad)? Are you satisfied with your current employment and education?Do you have any current or prior legal issues?(Required)Were you ever arrested or charged with a crime or misdemeanor? Do you have any involvement with the civil courts, such as a lawsuit or family law matters? If so, please describe them.What was life like as you were growing up, at home, in church, and in school?(Required)Did you meet developmental milestones on time or experience any delays? What were your friends like when you were younger? What was school like for you? What was your home life like?What strengths and abilities are you bringing to meetings? What needs or preferences do you have that will help us be successful?(Required)What coping skills have been working for you so far? What is important to know that will help make our time more effective for you? What are you strengths and weaknesses?What else would you like to share or is important to know about you or your family?(Required)Share whatever else you would like here.EmailThis field is for validation purposes and should be left unchanged. Δ