New Client Worksheet Cheri Rohlman, MA

A Celebration of Change
104 W Main St, Ste 203
Puyallup, WA 98371
(253) 770-2332

Date: ______________________

First Name: _____________________________ Last Name: ________________________________

Address: ___________________________________________________________________________

Phone: ________________________________ Cell Phone: __________________________________

Employer: ____________________________________ DOB: __________________________

Circle: Male Female

Single Married Separated

Employed Student Unemployed

Why are you here today?

___________________________________________________________________________________________________________

_______________________________________________________________________________________

How long has this been going on? _____________________________________________________________________

Have you received Mental Health Services before? Yes No Voluntary Involuntary

Previous psychiatric hospitalizations? Yes No Voluntary Involuntary

Does your family have a history of mental health problems? Yes No

Do you have any current medical or health issues? Yes No If yes, please explain below

___________________________________________________________________________________________________________

_______________________________________________________________________________________

Have you had any major medical problems in the past? Yes No If yes, please explain below

___________________________________________________________________________________________________________

_______________________________________________________________________________________ How is your current

primary care provider? ______________________________________________________________

When did you last see him or her? _____________________________________________________________________

Please list all medications you are taking; including over the counter drugs, vitamins, and herbs

Are you
Dosage/T Reason currently
Medication Name ime taking Prescribers name? taking?
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
Do you have allergies: Yes No If yes please list, include food, drugs, environmental and

reactions you have. 1.______________________________________ 2. ______________________________________

3. ._____________________________________ 4. ______________________________________

Substance use:

____ Caffeine: Amount: __________ How often: ___________ How long have you been using: __________

____ Tobacco: Amount: __________ How often: ___________ How long have you been using: __________

____ Alcohol: Amount: __________ How often: ___________ How long have you been using: __________

____ Inhalants: Amount: __________ How often: ___________ How long have you been using: __________

____ Marijuana: Amount: __________ How often: ___________ How long have you been using: __________

____ Drugs: Type: __________ Amount: __________How often: _________How long have you been using:

__________

Type: __________ Amount: __________How often: _________How long have you been using:

__________

Please list who lives in your home and your relationship to them.
Are they living in
Name: age: relationship: your home?
YES NO
YES NO
YES NO
YES NO
YES NO
 YES NO
YES NO
YES NO
YES NO
YES NO

Please list other important people involved in your life:

___________________________________________________________________________________________________________

_______________________________________________________________________________________

Spiritual Activities: Yes No If yes, please specify:

_________________________________________________________________________________________________

Education:

Less than high High school/ Associates/voc Undergrad Graduate

school GED ation degree degree

Are you experiencing financial problems? Yes No If yes, please circle which kind (Optional)

Budgeting Buying Food Housing Medical Bills

Clothing Legal fees Other:_________________________________

How did you hear about your therapist? ___________________________________________________

Additional Comments:

____________________________________________________________________________________

________________________________________ _________________________

Signature Date