Allison Bogdanoff, LCSW LLC

Personal Information Fact Sheet-Adult

 

Name:

Social Security #:

Address:

 

Telephone:

Date of Birth:

Education (highest grade completed):

Occupation:                                                                            Employer:

Employment History ( Brief description)

 

Marital Status:

Marital History:

Household Members:

            Spouse or Partners Name:

            Children in Household:

 

            Children not in Household:

 

            Others in Household:

Family History:          Name:                         Age:                 Residence (If living)

Mother:

Father:

Siblings:

 

Medical History:  (Describe important medical history including any hospitalization and/or significant illness):

 

 

List of Medications:               Dosage                                                Frequency

 

 

 

Primary Care Physician:                               Phone #:

Do you smoke? Y or N

Do you drink alcoholic beverages? Y or N    If yes, Amount:

Do you take or use chemical substance? Y or N   If yes, Amount:

Have you sought counseling before? Y or N    If yes, with whom and when:

 

For what reason:

 

Why are you seeking counseling at this time:

 

Any other information you wish to provide:

 

Signature of person complete form and relationship                                           Date: