Client Mental Health History Form

First name

Last name

Birthday

Month

Day

Year

Presenting Concerns

Please describe the main reasons you are seeking therapy/services at this time:

What is happening or is different? What stressors do you have? What do you hope will be different by seeking help?

How long have these concerns been affecting you?

When did it start? How often does it happen? How does it affect your life? How have you dealt with it so far?

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

If so, what was your experience like? When did it happen? Did you get help?

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

If so, who was it? Did they seek help or get a diagnosis? What was it like for them? What was it like for you?

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

If so, which? When did you start, how often did/do you use, and how long did this occur? Please list each substance separately.

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

Please list all individuals you consider to be a part of your family. For those who are not part of your family of origin (such as significant others), please include the duration of your relationship.

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

Did you meet developmental milestones on time or experience any delays? What were your friends like when you were younger? What was school like for you?

What social activities and relationships do you engage in?

What important social relationships do you have? Do you belong to any social clubs or organizations? How do you like to spend your leisure time?

What spiritual practices and cultural influences are important to you?

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

Do you have any current or prior legal issues?

Were you ever arrested or charged with a crime or misdemeanor? Do you have any involvement with the civil courts, such as a lawsuit or family law matter? If so, please describe them.

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

What coping skills have been working for you so far? What is important to know that will help make our time more effective for you?

What else is important to know about you?

Mental Health History

Have you previously participated in therapy or counseling?

If yes, please provide dates and provider names.

Have you ever received a diagnosis of a mental health condition from a healthcare professional? If so, what diagnosis did you receive?

Were you prescribed any medications for this diagnosis?

Have you ever been hospitalized for mental health concerns?

If yes, when and where?

Do you have any current or prior medical issues?

If so, what was/is it? Have you seen a doctor or other healthcare professional for it? What recommendations or treatment did you have? Is there any family history of disease?

Are you currently taking any medications - either prescribed or over-the-counter?

If so, please list the name, how much and how often you take it, what it's for, and who prescribed it.

Primary Care Physician Name and Phone number?

Substance Use History

Do you currently use any of the following substances?

If yes, please describe frequency and amount:

Have alcohol or drug use ever resulted in legal consequences for you?

Family & Social History

Who lives in your household?

Do you have a support system (friends, community, groups)?

Please describe.

Any family history of mental health or substance use concerns?

If yes, who and what medical issues were they diagnosed with?

Trauma & Safety Screening

Have you experienced any of the following?

Would you like to discuss these concerns in therapy?

Yes

No

Are you currently experiencing any abuse or feeling unsafe?

Yes

No