client questionnaire - Northlight Counseling

Client Questionnaire

Before filling out the Client Questionnaire, please review the Client-Counselor Agreement. You must agree with all of the terms and conditions stated therein before submitting this Client Questionnaire.

1. Are you seriously considering suicide? If you answered ‘YES’ to any of the questions on the left, online and telephone counseling is NOT for you and we suggest you contact a mental health professional in your local area. If you are considering suicide, please call 1-800-273-TALK (8255) or click here.
2. Are you in the midst of a serious emotional crisis?
3. Do you have intense or serious emotional problems?

First Name: Last Name:
Street Address: City:
State: Zip Code:
Telephone: *Email:
*Age: *Confirm Email:
Gender: Marital Status:
Employment Status: Do you enjoy your work?
Type of work you do: Highest level of education achieved

How did you find out about  What search engine or key words did you use?
Please describe the main reason you’re contacting me- including a question:
What would you like to gain from the counseling experience?
If you have received any type of counseling services in the past, please describe when and for what:
If you have received counseling services in the past, what did you like and dislike about your experience?
List all individuals living in your home (first name, sex, age and relationship):
If you have other children who do not currently live with you, list their first name, sex and age:
If you have been married previously, please list the duration (month/years) of each marriage:
What things about you or your family would be helpful for me to know? (illnesses, handicaps, deaths, divorces, school/job changes, suicide, etc.)
List any major health problems you have:
List any
medications you currently take:
How much and how often do you drink alcohol?
Which alcoholic beverages do you currently drink?
Beer   Wine   Mixed Drinks   Hard Liquor   None
List any other substances you currently use, and how often? (drugs, smoking, etc.)
List any other substances you’ve used in the past, and when you quit?
What day/time(s) are most convenient for you to participate in online or telephone counseling sessions?
What type of counseling are you most interested in?
I acknowledge that I have read the Client-Counselor Agreement and agree with all of the terms and conditions stated therein:
Agree    Disagree