Phyllis Lorenz, MFT
1425 Leimert Blvd. Suite #202
Oakland, CA 94602
510-869-5602
CLIENT PERSONAL INFORMATION
Contact information
Full name _________________________________ Date of Birth ____________________
Home address _________________________________ Home telephone __________________
_________________________________ Work telephone __________________
E-mail address ____________________________ Cell phone __________________
Background
Ethnic background ______________ Sexual orientation ______________
Religion raised (if any) ______________ Religion now (if any) ______________
How would you describe your class background? _____________________________________________
Current job, career or line of work (if any) __________________________________________________
Do you have a significant other relationship e.g. spouse, partner, girlfriend, boyfriend? (Yes/No)
Name _______________________________________ Date of Birth _______________
Relationship to you (e.g. married, separated, living apart, never married) __________________________
How long have you been married or lived together (if applicable)?________________________________
Separated (Yes/No) Date(s) _______________ Divorced (Yes/No) Date(s) _______________
Who referred you to me? ______________________________________________________
Names and ages of children (if any).
Medical History
Physician _____________________________________________ Phone___________________
Psychiatrist____________________________________________ Phone __________________
Current Medications _____________________________________________________________
Prior Medication use & dates______________________________________________________
Non Prescription Drug / alcohol use_______________________ Frequency of use _________
What do you enjoy doing for exercise? _________________________ Frequency____________
Trauma history (if any)
Did you have traumatic experiences in your childhood and adolescence (e.g. emotional neglect, abuse by a caregiver, car accident, discrimination, divorce of parents, loss of loved ones, school or sibling bullying)? If so, please describe.
Have you had traumatic experiences in your adult life? If so, please describe.
Goals for therapy
Have you received psychotherapy or counseling before? (Yes/No). If so, say with whom and give dates.
If therapy is successful, what will be different in your life? (Use reverse of sheet if you need more space)
Current symptoms.
Please tell me which of the following, if any, are present in your life by circling one of the numbers after each item? (1 means not at all, and 5 means at a high level
Easily stressed 1 2 3 4 5
anxiety 1 2 3 4 5
panic attacks 1 2 3 4 5
irritability 1 2 3 4 5
mood swings 1 2 3 4 5
anger and explosivity 1 2 3 4 5
feeling powerless when facing conflict 1 2 3 4 5
thoughts of revenge 1 2 3 4 5
nightmares 1 2 3 4 5
difficulty sleeping 1 2 3 4 5
difficulty relating to groups 1 2 3 4 5
difficulty relating to intimate partner 1 2 3 4 5
gastrointestinal complaints 1 2 3 4 5
headaches and migraines 1 2 3 4 5
back or neck pain 1 2 3 4 5
widespread muscle tension and/or myalgia 1 2 3 4 5
feeling separate from your body 1 2 3 4 5
feeling your surroundings are unreal 1 2 3 4 5
intolerance to light and/or sound 1 2 3 4 5
sexual problems or troubling fantasies 1 2 3 4 5
eating disorders 1 2 3 4 5
alcohol or drug dependence 1 2 3 4 5
workaholism 1 2 3 4 5
other addiction: specify ___________ 1 2 3 4 5
low energy and fatigue 1 2 3 4 5
depression 1 2 3 4 5
feelings of loneliness 1 2 3 4 5
low self‑esteem 1 2 3 4 5
shame 1 2 3 4 5
What things do you do well?
Who do you look to for support?
Is there anything else that would you like me to know about you?
Signature ____________________________________ Today’s date ___________________