Integration Course

Download:  MSWORD

Client History Information




Purpose of this questionnaire:


The purpose of this questionnaire is to obtain a comprehensive picture of your background.  By completing these questions as fully and as accurately as you can, you will facilitate your therapeutic program.  If the answer space provided is not adequate, please use the backs of the sheets of paper.


It is understandable that you might be concerned about what happens to the information about you because much or all of this information is highly personal.  Case records are strictly confidential.  NO OUTSIDER IS PERMITTED TO SEE YOUR CASE RECORD WITHOUT YOUR PERMISSION.


If you do not desire to answer any questions, merely write: DCA (Do not Care to Answer).



NAME_________________________ AGE_______ DATE OF BIRTH____________________


HOME ADDRESS ________________________________________________ZIP__________


HOME PHONE _________________ SEX     M     F     (Circle one)


SOCIAL SECURITY NUMBER _________________________




EMPLOYER _________________________________________