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*

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

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