Name                                                                                          Age                  Birthdate                           

Address                                                                                      Email                                                             

City                                                                                              State                          Zip                             

Home Phone                                 Work Phone                                          Cell Phone:                                      

Occupation                                                                      Employer                                                                   

Marital Status                                          Name of Spouse/Partner                                                                      

How Long Have Both of You Been Together?                                  Religion                                                          

If Client is a Minor, Name of Responsible Adult                                                                                                    

Name of Closest Friend/Relative                                                                Phone                                                

Address                                                                          City                                     State           Zip               

There are times when prior medical and psychological records will be requested.

Please make sure that all information given below is correct.

Do You Smoke?                        How Much?                         Do You Drink?                        How Much?               

Do You Take Drugs?                  If yes, what kind?                                               How often?                               

Last Medical Examination                                   Reason                                                                                    

Are You Now Under a Doctor's Care?                   If yes, Doctor’s name:                                                               

Reason for Doctor’s Care:                                                                                                                                  

Are You Taking Any Medication?             If yes, what kind?                                                                                       

Reason for Medication:                                                                                                                                   

Have You Ever Been Hospitalized for a Physical Illness?   Describe:                                                                     

Have you ever been Hospitalized for a Mental Illness, Personality Disorder, Anxiety Disorder, etc? Describe:                                                                                                                                                                        

Any Previous Therapy/Counseling?                  If Yes, Name and Phone Numbers of Therapists:                                                                                                                                                           

When and Number of Sessions:                                                                                                                         

Type of Therapy/Counseling:                                                                                                                              

How referred to Dr. Hannig: