Spirituality Course
Return

Download:  MSWORD

Client History Information

Adults

 

 

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 _________________________

 

APPROXIMATE FAMILY INCOME BEFORE TAXES $___________________

 

EMPLOYER _________________________________________