Full Name
Date of Birth
Gender
Contact Numbers
Primary
Alternate
Emergency
Patient Photo
The following sections help clinicians understand the client’s psychological, emotional, and social background.
Main issue(s) brought by the client
Client’s own words for the problem
Duration of concern
Recent trigger or stressor
Previous therapy or counseling
Past diagnosis (if any)
Psychiatric hospitalization
Response to past treatment
Current psychiatric medications
Past medications
Side effects experienced
Medication adherence
Mental health issues in family
Substance use in family
Suicide or self-harm history
Family structure
Current living situation
Education / occupation
Support system
Recent losses or changes
Relationship conflicts
Academic / work pressure
Financial concerns
Alcohol use
Smoking / tobacco
Recreational substances
Frequency and duration
Suicidal thoughts (past / present)
Self-harm behavior
Homicidal thoughts
Protective factors
Appearance and behavior
Speech pattern
Mood and affect
Thought process
Insight and judgment
Coping skills
Motivation for therapy
Supportive relationships
Key psychological issues identified
Provisional diagnosis (if applicable)
Therapy approach explained
Session frequency suggested
Short-term goals set
Follow-up session scheduled
Address Line 1
Address Line 2
Postal Code
State
City
Referred By
Source
Previous Hospital
Doctor Visited
Period