Client Name: _____________________________________________________ Date: ________________
I am here to see: Crystal Duncan, LCSW, CA61763
What brings you to therapy today? _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________
_____________________________________________________________________________________
Client Information
Age: _______ D.O.B: ___________________ S.S.N.: _______________________
Occupation: ___________________________________________________ How Long: ______________ Employer/School: _______________________________________________________
Marital status:
Married • Remarried • Single • Single Parent • Widow(er) Divorced • Separated • Partnered
Spouse’s / Partner’s Name: ______________________________________________________________
Do you have children? If yes, names & ages__________________________________________________ _____________________________________________________________________________________
Who lives in your home? ______________________________________________
Home Address: ______________________________________________________
_______________________________ , _______________________ , ____, _______
Primary Phone: ______________________ Secondary Phone: ______________________
May your SSCS therapist leave a message for you at Primary Number and/or Secondary Number? Y or N
Permanent Address (same as above____)
Other: ______________________________________________________________________________
Have you ever seen a mental health professional (psychiatrist, psychologist, or counselor)? Y or N
If yes, when? _________________________________________________________________________
Please briefly list the reasons: ____________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________
Are you currently taking any medication? Y or N
If yes, explain: _________________________________________________________________________ _____________________________________________________________________________________
Can your SSCS therapist contact you via email to discuss scheduling and other related issues? Y or N
E-Mail: _____________________________________________________________
Signature: ___________________________________________ Date: __________
Printed Name: _______________________________________________________
I am here to see: Crystal Duncan, LCSW, CA61763
What brings you to therapy today? _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________
_____________________________________________________________________________________
Client Information
Age: _______ D.O.B: ___________________ S.S.N.: _______________________
Occupation: ___________________________________________________ How Long: ______________ Employer/School: _______________________________________________________
Marital status:
Married • Remarried • Single • Single Parent • Widow(er) Divorced • Separated • Partnered
Spouse’s / Partner’s Name: ______________________________________________________________
Do you have children? If yes, names & ages__________________________________________________ _____________________________________________________________________________________
Who lives in your home? ______________________________________________
Home Address: ______________________________________________________
_______________________________ , _______________________ , ____, _______
Primary Phone: ______________________ Secondary Phone: ______________________
May your SSCS therapist leave a message for you at Primary Number and/or Secondary Number? Y or N
Permanent Address (same as above____)
Other: ______________________________________________________________________________
Have you ever seen a mental health professional (psychiatrist, psychologist, or counselor)? Y or N
If yes, when? _________________________________________________________________________
Please briefly list the reasons: ____________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________
Are you currently taking any medication? Y or N
If yes, explain: _________________________________________________________________________ _____________________________________________________________________________________
Can your SSCS therapist contact you via email to discuss scheduling and other related issues? Y or N
E-Mail: _____________________________________________________________
Signature: ___________________________________________ Date: __________
Printed Name: _______________________________________________________
