General Information

I find that having the following information is frequently helpful to me for both clinical reasons and sometimes in the case of emergency situations. If you are uncomfortable having some of this information written and part of your clinical record, please feel free to leave that/those spaces blank and we can talk about it instead.

Name : ______________________________________________________________________

Date of Birth : ___________________________________

Today's Date : ________________________________

Home Address:

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Street

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City/State/Zip

Mailing Address (if different than home address):

______________________________________________________________

Street

______________________________________________________________

City/State/Zip

Email : _________________________________________________________ (Ok to email? Yes/No)

Home Phone : _______________________________________

Ok to call? Yes/No Ok to leave messages? Yes/No

Work Phone : ________________________________________

Ok to call? Yes/No Ok to leave messages? Yes/No

 Cell Phone : _________________________________________

Ok to call? Yes/No Ok to leave messages? Yes/No

Okay to text message? Yes/No

Insurance ? ____________________________________________________________________________________

Company ID Group ID Subscriber/Date of Birth

Emergency Contacts :

___________________________Relationship:______________________Phone:_________________________

Referred By _________________________________________________________

How did you find me/my practice?_________________________________________________

Tell me a bit about what brings you to therapy right now.

What do you hope to achieve/receive from therapy/counseling?

Have you been to therapy/counseling before? If yes, when, and what prompted you to seek therapy? What was most helpful about the therapy experience?

Are you currently under medical care? If yes, briefly explain?

Are you currently on any medications? If yes, what medications? Note, please list any psychiatric medications you are taking currently or have taken in the past. Also, please note what medications have/are helpful for you.

Do you drink alcohol? If so, how much and how often?

Do you use any recreational drugs? If so, how much and how often?

Is there anything else I should know before we begin?

Is there anything you would like to know about me?

NOTE: All of your records and any other information about your contact with Eileen Stein, MSSW, LICSW is CONFIDENTIAL. Your written consent is required before I can release any such information, except in the event of a life-threatening situation or as required by law.

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Signature/Date

Eileen Stein, MSSW, LICSW, ACSW 1818 Westlake Avenue North, Suite 124 Seattle , WA 98109 206.937.3972