Adult Client Questionnaire

Welcome. Thank you for choosing Child Guidance & Family Solutions. Please complete all of the information below. It is valuable and needed to better understand you as well as to meet the standards of our accrediting bodies.

CLIENT INFORMATION


 
 

Male   Female

Male   Female   Other  

Home   Work   Cell  

Yes   No  

Married  
Unmarried couple  
Divorced  

Separated   Never Married   Widowed  

Full-time    Part-time    Disabled    Homemaker    In the Armed Forces
Not in Labor Force    Retired    Student

Alaskan Native    American Indian    Asian    Black/African American    Pacific/Islander/Hawaiian
Two or more Races    Unknown    White/Caucasian

Not of Hispanic Origin    Cuban    Mexican/Mexican-American    Other Hispanic    Puerto Rican    Unknown

EMERGENCY CONTACTS


Who should we contact in case of emergency person? Contact person needs to be local.

PRIMARY INSURANCE INFORMATION: Bring Copy of Current Card(s)



Self   Spouse/Partner   Mother   Father   Other  

SECONDARY INSURANCE INFORMATION: Bring Copy of Current Insurance Card(s)



Self   Spouse/Partner   Mother   Father   Other  

SPOUSE/PARTNER INFORMATION (if applicable)



Male   Female

Full-time    Part-time    Disabled    Homemaker    In the Armed Forces
Not in Labor Force    Retired    Student

CHILDREN


Yes   No
Male   Female
Yes   No
Male   Female
Yes   No
Male   Female
Yes   No
Male   Female
Yes   No
Male   Female

OTHERS IN THE HOME


CURRENT LIVING ARRANGEMENTS


Homeowner    Rent    Friend's Home    Relative's Home    Supervised Group Home    Crisis Residential    Supervised Apartment
Boarding Home    Foster Adult Care    Homeless    Other   

No   Yes

No   Yes

No   Yes

NUTRITIONAL INFORMATION



No   Yes

No   Yes

No   Yes, an INCREASE in appetite Yes, a DECREASE in appetite

No  
Yes, weight LOSS, how much?
Yes, weight GAIN, how much?

No   Yes

No   Yes

No   Yes

MEDICAL HISTORY


Thyroid Problems
Diabetes
Asthma
Dental Problems
Food Allergies
Depression
Anxiety Attacks
Hallucinations
Any other significant health concerns
Other Allergies
No   Yes

PHYSICAL EXAM HISTORY



No   Yes

I agree that the above is true and correct to the best of my knowledge.