Get Please Fill Out This Form For Yourself And All Family Members And/or People Living In The Home

Filling out the Please Fill Out This Form for yourself and all family members and/or people living in the home is an important step in providing accurate information for counseling services. This guide will help you navigate each section of the form with clarity and confidence.

Follow the steps to successfully complete the form online.

1. Click the ‘Get Form’ button to access the form and open it in your preferred online editor.
2. Complete the client information at the top of the form. Fill in your full name, birthday in the specified format (M/D/Y), and contact details including email and phone numbers (cell, home, and work). Also, provide your street address, city, state, and zip code.
3. For each family member or person living in the home, provide their name, birthday, email, contact numbers, and address. Specify each individual’s relationship to you in the designated field.
4. Indicate whether you or any family members have previously received counseling, including any hospitalizations. If applicable, list the names and the places and dates of these experiences.
5. Select whether the previous counseling was helpful and include your reasoning if prompted.
6. Detail any major medical problems your client has experienced, including the duration.
7. Provide emergency contact information, including the person’s relationship to you and their phone number.
8. Specify if you would like to receive automated appointment reminders, and indicate your preferred method of receiving these reminders (text, voicemail, or email).
9. List your primary care physician’s name, address, and contact information. Record all current medications prescribed by them.
10. Respond to questions regarding substance use, including nicotine, alcohol, marijuana, and any unauthorized substances. Describe your usage patterns, if applicable.
11. Answer questions regarding your mental health and any suicidal thoughts, and specify if you have safety concerns for yourself or others.
12. Identify who referred you to the counselor and indicate if it is acceptable to send a thank you note.
13. Complete the checklist of problems that apply to you, indicating your reasons for seeking therapy and any additional comments.
14. Once all sections are complete, save your changes, and you can choose to download, print, or share the form as needed.

Begin completing your documents online today for a seamless experience.