FINANCIAL AGREEMENT FOR COUNSELING



CONFIDENTIAL CLIENT INFORMATION

Name(s):________________________________________ Phone(s):_______________________

Other Family Members Attending:_________________________________________________________

Address:_______________________________________ DOB:_______________________

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Briefly describe problems or reasons for coming here:_________________________________________

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Significant life events:__________________________________________________________________

_____________________________________________________________________________________

Indicate major stress sources in your life:____________________________________________________

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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: |

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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:_________________________

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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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