FINANCIAL AGREEMENT FOR COUNSELING
CONFIDENTIAL CLIENT INFORMATION
Name(s):________________________________________ Phone(s):_______________________
Other Family Members Attending:_________________________________________________________
Address:_______________________________________ DOB:_______________________
____________________________________________________________________________
Briefly describe problems or reasons for coming here:_________________________________________
____________________________________________________________________________________
Significant life events:__________________________________________________________________
_____________________________________________________________________________________
Indicate major stress sources in your life:____________________________________________________
_____________________________________________________________________________________
What solutions have you tried or thought about trying to solve the problem:________________________
_____________________________________________________________________________________
Referred by:__________________________________________________________________________
Present Family Life:
Marital Status: (check one)
Single ☐ Married ☐ In a relationship ☐ Length of time:_____________________
Spouse or significant other’s name:__________________________________ Age:________
Divorced ☐ Date of divorce:__________________ Widowed ☐ Separated ☐
Have you had any previous marriages/long-term relationships: No ☐ Yes ☐
How many:_____ From/To:_________________
Children:
|Name: |Age: |Sex: |School Attending/Employment: |
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Overall impression of present family life:____________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Present Occupation:___________________________________________________________________
Employment History:
| |Employer: |Time: |Length of time: |Job Satisfaction: |
|Current: | |Part ☐ Full ☐ | |Good ☐ OK ☐ Poor ☐ |
|1st Previous: | |Part ☐ Full ☐ | |Good ☐ OK ☐ Poor ☐ |
|2nd Previous: | |Part ☐ Full ☐ | |Good ☐ OK ☐ Poor ☐ |
Childhood Family Life:
Father’s Name:______________________________________________
Age:________________ If deceased, date of death:______________________
Mother’s Name:______________________________________________
Age:_______________ If deceased, date of death:_______________________
Siblings:
|Name: |Age: |Sex: |
| | | |
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Please check the following items that best describe your childhood:
Happy ☐ Sad ☐ Loving ☐ Painful ☐
Confusing ☐ Exciting ☐ Boring ☐ Can’t remember much ☐
Your overall impression of your childhood family life:_________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Education and Religion:
What is the highest level of education you completed:
Diploma/GED ☐ Some College ☐ Associates ☐ Bachelors ☐ Masters ☐ Doctorate ☐
Other:________________________________
Are you planning more education: Yes ☐ No ☐ Not sure ☐
Do you attend religious services: Yes ☐ No ☐ Sometimes ☐
If yes, denomination:_________________ Name of faith community:___________________________
List your hobbies and special interests:______________________________________________________
_____________________________________________________________________________________
Briefly describe your appearance and personality:_____________________________________________
_____________________________________________________________________________________
What do you see as your strengths:_________________________________________________________
_____________________________________________________________________________________
What do you see as your weaknesses:_______________________________________________________
_____________________________________________________________________________________
Military Service/Legal Issues:
Have you ever been in the military: Yes ☐ No ☐
Branch:_________________ Date Entered:______________ Date Discharged:______________
Have you ever had any legal problems: Yes ☐ No ☐
If yes, briefly describe:__________________________________________________________________
Have you ever been arrested: Yes ☐ No ☐
Arrest/Conviction History:_______________________________________________________________
_____________________________________________________________________________________
Probation Officer:___________________________________ Phone:_________________________
Medical/Psychological History:
Rate your present physical health: Excellent ☐ Good ☐ Poor ☐
Explain:______________________________________________________________________________
Major Medical Events:
|Serious illnesses, surgery and/or handicaps since childhood: |When: |
| | |
| | |
| | |
Physician’s Name:________________________________________ City:_____________________
Date of last physical exam:_______________________ Reason:______________________________
Findings:_____________________________________________________________________________
Psychological & Physical Medications:
|Medication Name: |Dosage: |Reason for taking: |
| | | |
| | | |
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Rate your present mental health: Excellent ☐ Good ☐ Poor ☐
Previous Counseling Experience:
|Therapist Name: |Phone: |Agency/Address: |To/From: |Reason: |
| | | | | |
| | | | | |
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Progress:_____________________________________________________________________________
Reason counseling terminated:____________________________________________________________
How will you measure the success or failure of this counseling experience:_________________________
_____________________________________________________________________________________
Do you drink alcoholic beverages: Yes ☐ No ☐ If yes, which: Beer ☐ Wine ☐ Liquor ☐
If yes, how much do you drink/how often:____________________________________________________
Has your alcohol consumption ever been a problem: Yes ☐ No ☐
If yes, briefly explain:_______________________________________________________________________
Do you use drugs: Yes ☐ No ☐ If yes, what do you use/how often:______________________________
Has your drug usage ever been a problem: Yes ☐ No ☐
If yes, briefly explain:___________________________________________________________________
Have you been treated for substance abuse: Yes ☐ No ☐
If yes, what substance, when and where:____________________________________________________
Have you had any suicidal thoughts/attempts, or self injury: Yes ☐ No ☐
If yes, explain:_______________________________________________________________________
___________________________________________________________________________________
In case of an emergency, contact:
Name:________________________________________ Phone:___________________________
Relationship:_______________________________
I certify that the information provided above is true to the best of my knowledge and belief.
Client Signature:_______________________________________ Date:______________________
I have reviewed the contents of this form and have discussed same with the client.
Therapist Signature:________________________________________ Date:__________________
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