Tia Harms LLC Ph. 503.559.

2233
Counseling for Individuals, Couples, or Groups tiaharms@hotmail.com

Complete the following form to the best of your ability and bring with you to initial session. Use
reverse for additional writing space if necessary.
Client Name: Date:

Phone: Is it safe to leave a message: Y / N

Gender: Age: DOB: Ethnicity:

1. What led you to call about counseling?

How did you hear about my services?

2. Have you had counseling in the past? (If so, describe):

3. Do you have any health concerns? Taking medications (If so, please list)?

4. Physical and Medical Information (in/out patient treatment, hospitalization, disabilities):

5. Describe your history with alcohol and/or drugs:

6. How much do you presently drink? Use drugs? Tobacco?

7. Family of Origin Information (Describe parents, siblings, relatives; self as a child; significant
memories; primary relationships):

8. Social Support (Friends, social network; quality/quantity; recreation):

9. Religious/Spiritual Beliefs. Share any values in this area you think important for me to know:
Tia Harms LLC Ph. 503.559.2233
Counseling for Individuals, Couples, or Groups tiaharms@hotmail.com
10. Educational/Vocational Information (last grade completed; current job; history of job changes;
reasons for terminations; military):

11. Legal Information (protection orders, litigation (status/type), arrests, probation, custody, etc.):

12. Have you experienced depression? (If so, please describe symptoms):

Had suicidal thoughts? Any past attempts?

Any planning?

13. Have you felt aggressive or violent against others?

14. Have you ever been in situations or relationships where you have felt verbally abused?
• Example: threats, name calling, controlling, isolating, overly jealous, limiting access to money,
friends, or family, etc.
Details:

How long ago did this occur?

Last contact with them (date): Reason:

15. Have you ever been in situations or relationships involving physical violence?
• Example: hit, shoved, restrained, choked, objects thrown at, kicked, sexual abuse, burned,
pinched, harmed with weapons or other objects, hair pulled, bitten, etc.
Details:

When was the last incidence of violence?

Last contact with them (date): Reason:

Do you feel safe at this time? (explain):