Forms

These PDF forms can be downloaded for your convenience. Please complete each form prior to your first session. You can submit them via scan/email, fax or simply bring them to the session.

Preliminary Information

Fill out Form

Anew Place Counseling Services, Inc.

Kevin Barwick, LCPC, MHt

PRELIMINARY INFORMATION

Please complete the information in the spaces below. Any information related to your association with Anew Place Counseling Services, Inc. is regarded as strictly confidential and will not be shared with anyone without your signed consent.

NAME:
DATE:
Date Format: MM slash DD slash YYYY
Phone
GENDER:
- Male
- Female
DOB:
Date Format: MM slash DD slash YYYY
AGE:
MARITAL STATUS:
- Married
- Single
- Divorced
- Widowed
ADDRESS:
CITY:
STATE/ZIP:
E-MAIL ADDRESS
CELL #:
EMPLOYER:
WORK #:
WORK ADDRESS:
CITY/STATE/ZIP:
LENGTH OF CURRENT EMPLOYMENT:
POSITION:
SOCIAL SECURITY NUMBER:
SPOUSE’S NAME AND OCCUPATION:
WITH WHOM DO YOU RESIDE?
WHAT COUNSELING EXPERIENCE HAVE YOU HAD? HOW LONG? WITH WHOM?
Phone
WHAT DID YOU ACCOMPLISH IN COUNSELING?
WHAT MEDICATIONS OR DRUGS ARE YOU CURRENTLY TAKING (DOSAGE)?
HOW DID YOU HEAR ABOUT ANEW PLACE/KEVIN BARWICK?
PERSON TO NOTIFY IN CASE OF EMERGENCY:
ADDRESS:
CITY/STATE/ZIP:
PHONE NUMBER:
RELATIONSHIP:

Life History Questionnaire

Fill out Questionnaire

LIFE HISTORY QUESTIONNAIRE

(Confidential)

Name:
First
Date of Birth:
Date Format: MM slash DD slash YYYY
Place of Birth:
Please give a brief description and history:
1. Current Challenge: List three main problem or challenge areas (e.g. stress, marital tension, depression, etc.) and their possible causes.
2. Current Changes (please circle all that apply):
- A. Change in sleep pattern
- E. Decreased concentration
- B. Change in appetite
- F. Increased anxiety
- C. Decreased energy
- G. Suicidal feelings
- D. Decreased motivation
- H. Other (please list)
3. Please give at least one example of where and/or how you are having difficulty functioning:
4. Would you say your first 15 years was traumatic or uneventful? List 2-3 traumatic events:
5. Describe your father:
6. Describe your mother:
7. Describe your siblings (names, ages, your relationship with them, etc.):
8. Describe your marriages (how long they lasted, spouses’ characteristics, why they may have ended, etc.):
9. Describe your education (when, where, degrees, etc.):
10. Describe your children (names, ages, characteristics, etc.):
11. Describe your religious background and any current involvement:
12. Complete the sentences:
If I could change the world, I would
What I most like about myself is
What I would change about myself is
Something most people don’t know about me is
Something I want most for people to know about me is

Consent Form

Forms

Anew Place Counseling Services, Inc.

LIFE HISTORY QUESTIONNAIRE

Please give a brief description and history:

12. Complete the sentences:

Anew Place Counseling Services, Inc.