Client Information Form

Alan Behrman & Associates, PC

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

*This form is completely confidential*

Today's date :

Date of Birth

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

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:

Client Information Form

Alan Behrman & Associates, PC

Client Information Form

MEDICAL HISTORY:

FAMILY:

RELATIONSHIPS & SOCIAL SUPPORT & SELF-CARE:

EDUCATION & CAREER

Anxiety

People in General

Nausea

FAMILY HISTORY OF (Check all that apply):