Client Information

Submittal Date	*		Complete and forward to DR. Kelly for Online Counseling
Name	*		Address	*
City	*		State	*
Home Phone	*		Work Phone
Mobile Phone			Email	*
Country	*		Marital Status	*	Married Divorced Separated Single Widowed
Gender	*		Date of Birth	*
SS#	*		Family Members
Education (Specify)	*		PCP Information (Name, Address, Phone#)
Specify Service Type	*	New Client Referral In Office Therapy Distance Counseling Hypnotherapy EMDR Virtual Reality Photo Stimulation One Brain Individual Family Couples/Marriage Career Self Improvement	Online Internet Experience	*	Computers Email Encrypted Email Live Chat Video Chat/Conferencing Chat Rooms Blogs Voice Over IP
Computer Set Up	*	Windows 9x/Me Windows XP/Vista MacOS Linux/Unix Internet Explorer Mozilla Safari Other	Internet Connection	*	Dial Up Broadband DSL Fiber Optics
Provide the following information. This information will assist Dr. Kelly in determining the appropriateness of In Office and/or On Line Distance Counseling. All information is confidential and will not be shared with others.			State any prior counseling experience	*
State reason for previously seeking counseling	*		State current symptoms? (Specify)
What have you done to resolve your issues?	*		State any current medications	*
State any drug or alcohol use	*		State any family history of drug or alcohol use	*
State any family history of mental/emotional problems	*		State any family history of physical abuse	*
State any family history of sexual abuse	*		State any family history of domestic violence	*
State any non-familial experiences w/ abuse	*		State any eating problems	*
State any sleeping problems	*		State any financial problems	*
State any legal problems	*		State any medical problems
State any school/work related problems	*		State any relationship issues	*
Indicated any family support systems	*		Add additional comments which will help to better understand your situation	*
What event has had the greatest impact on you?	*		Have you ever been arrested?	*
Check all that apply	*	Depression Anxiety Anger Agitation Panic Attacks Phobias Irritability Low Energy Aggressiveness Conduct Problems Sleep Problems Eating Problems Binging/Purging Anorexia Loose Associations Paranoia Lability Impaired Memory OCD Oppositional Sexual Dysfunction Delusions Hallucinations Suicidal Ideation Homocidal Ideation Psychomotor Retardation	Inoffice Insurance Form
Security Code	*		Disclaimer Read & Accepted	*