Client History Form

Request for Instructions From Practice: Please complete the questionnaire to the best of your ability, then submit below.

    Why are you seeking help now?

    Please give more details about the issue you named above:

    Have you ever experienced similar or other mental health symptoms before?

    Has anyone in your family ever experienced mental health or substance use issues?

    Do you have any current or prior medical issues?

    Are you currently prescribed any medications?

    Do you now, or have you ever, used alcohol, tobacco, recreational drugs, or prescription medication other than as prescribed?

    Who is in your family? What is your relationship with them like?

    What social activities and relationships do you engage in?

    What spiritual practices and cultural influences are important to you?

    What was life like as you were growing up, both at home and in school?

    What significant educational and work/volunteer experiences have you had?

    Do you have any current or prior legal issues?

    What strengths and abilities are you bringing to sessions? What needs or preferences do you have that will help us be successful?

    What else is important to know about you?

    Client portal for Jackson Marriage and Family Counseling Services

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