Biodata Form for Consultant

BIOGRAPHICAL INFORMATION
Please fill out this biographical background sheet as completely as possible. It will help me in
our work together. All information is confidential as stated in the Counseling Agreement Form.
If you do not desire to answer a particular question, please indicate it on the form. Please bring
this package, signed and filled out, to your next session.
Name: _________________________________________ male/female __________
Address: _____________________________________________________________
Phone: h ___________________ w ___________________ c __________________
DOB: ______________ Place of Birth: ___________________________________
Person & phone# to call in emergency: ____________________________________
______________________________________________________________________
Occupation/Employer: __________________________________________________
Relationship Status/Living Arrangement: __________________________________
Significant Past Relationships:_____________________________________________
_______________________________________________________________________
Children (incl. Step- or grand-): ____________________________________________
_____________________________________________________________
Referral Source: ________________________________________________________
Presenting Problem(s) (be as specific as possible: time it started; how it affects you or others
around you; etc.): ___________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
Estimated Severity of ….
Problem 1: mild _____ moderate _____ severe ____
Problem 2: _____ _____ _____
Problem 3: _____ _____ _____
Medical Doctor(s) (name & phone#):_________________________________________
_____________________________________________________________
_____________________________________________________________
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