Tom Hansen, Ph.D., LCSW
Counseling and Consultation
Relationships and Mental Health
BASIC INFORMATION FORM
This information will provide background information about you
or the person you are bringing & will help provide better
services to you. Please provide the information requested as
completely as possible. If you can’t answer a question or are
unsure of how to answer, please skip the question. All
information is confidential & cannot be discussed with anyone
without your permission, within the limits of the law.
Full Name: Date of
Gender: M F
Insured’s Place of Employment & Address:
Relationship Status: Single
Number of previous marriages:
Years in current/previous marriage:
Children’s names and ages:
Names/ages/relationships of people living in your household:
General Health: Present state of your health:
Chronic health problems:
Last physical exam:
Primary Care Physician:
Name, phone and relationship of person to contact if there is
Who referred you to me?
What is the reason for your seeking my services?
How long have you had this concern?
How did the problem start?
Has this been a problem before?
Past/present use of drugs, including caffeine & tobacco:
Have you ever received counseling in the past?
If yes, when
& with whom?
Unemployed (how long)?
Highest grade completed:
Location of employment:
This form is designed to help me gather information to
evaluate your needs and develop a plan that fits you and your
circumstances. If you have additional comments, questions or
information you’d like to share about yourself, please do so
below. Thank you.
Additional comments, questions or information:
Credit Card Information:
Credit Card Type: Visa
Credit Card Number:
Name on Card:
Signature of person completing form
End - Part 2