Alan Behrman & Associates, PC

    2876 Johnson Ferry Rd., Suite 150 Marietta, GA 30062
    770-361-7864 [email protected]


    Client Information Form

    *This form is completely confidential*

    May I have your permission to thank this person for the referralYesNo

    If referred by another clinician, would you like for us to communicate with one another?
    YesNo

    Person(s) to notify in case of any emergency:

    I will only contact this person if I believe it is a life or death emergency. Please provide your name to indicate that I may do so:


    *The following information on this form will help guide your treatment. Please try to fill out as much as you are comfortable disclosing.*

    MEDICAL HISTORY:

    Current Medications:

    Do you smoke or use tobacco? YesNo

    Do you consume caffeine? YesNo

    Do you drink alcohol? YesNo

    Do you use any non-prescription drugs? YesNo

    Have anyone voiced concern about your substance use? YesNo
    Have you ever been in trouble or in risky situations because of your substance use? YesNo

    HeterosexualLesbianGayBisexualTransgender


    FAMILY:

    Were there any other primary care givers who you had a significant relationship with? If so, please describe how this person may have impacted your life:


    RELATIONSHIPS & SOCIAL SUPPORT & SELF-CARE:

    Previously Married/Life Partnered? YesNo


    EDUCATION & CAREER

    High School/GEDCollege DegreeGraduate DegreeVocational Degree


    Please check all that apply:

    Anxiety

    Depression : NowPast
    Mood Changes : NowPast
    Anger or Temper : NowPast
    Panic : NowPast
    Fears : NowPast
    Irritability : NowPast
    Concentration : NowPast
    Headaches :NowPast
    Loss of Memory : NowPast
    Excessive Worry :NowPast
    Feeling Manic : NowPast
    Trusting Others : NowPast
    Communicating with Others :NowPast
    Drugs : NowPast
    Alcohol : NowPast
    Caffeine : NowPast
    Frequent Vomiting : NowPast
    Eating Problems : NowPast
    Severe Weight Gain : NowPast
    Severe Weight Loss : NowPast
    Blackouts : NowPast

    People in General

    Parents : NowPast
    Children : NowPast
    Marriage/Partnership : NowPast
    Friend(s) : NowPast
    Co-Worker(s) : NowPast
    Employer : NowPast
    Finances : NowPast
    Legal Problems : NowPast
    Sexual Concerns : NowPast
    History of Child Abuse : NowPast
    History of Sexual Abuse : NowPast
    Domestic Violence : NowPast
    Thoughts of Hurting Someone Else : NowPast
    Hurting Self : NowPast
    Thoughts of Suicide : NowPast
    Sleeping Too Much : NowPast
    Sleeping Too Little : NowPast
    Getting to Sleep : NowPast
    Waking Too Early : NowPast
    Nightmares : NowPast
    Head Injury : NowPast

    Nausea

    Abdominal Distress : NowPast
    Fainting : NowPast
    Dizziness : NowPast
    Diarrhea : NowPast
    Shortness of Breath : NowPast
    Chest Pain : NowPast
    Lump in the Throat :NowPast
    Sweating : NowPast
    Heart Palpitations : NowPast
    Muscle Tension : NowPast
    Pain in joints : NowPast
    Allergies : NowPast
    Often Make Careless Mistakes : NowPast
    Fidget Frequently : NowPast
    Speak Without Thinking : NowPast
    Waiting Your Turn : NowPast
    Completing Tasks : NowPast
    Paying Attention : NowPast
    Easily Distracted by Noises : NowPast
    Hyperactivity : NowPast
    Chills or Hot Flashes : NowPast


    FAMILY HISTORY OF (Check all that apply):

    Drug/Alcohol ProblemsLegal TroubleDomestic ViolenceSuicide
    Physical AbuseSexual AbuseHyperactivityLearning Disabilities
    DepressionAnxietyPsychiatric Hospitalization“Nervous Breakdown