Maine Township

rlyon@mainetown.com

1700 Ballard Road, Park Ridge, IL, 60068, US

847-297-2510

Client Information

Client's Full Name

Client's Gender

Client's Date of Birth

Your Full Name

Your Relationship to Client

Address

Enter an address

Street Address Street Name

Apt, Suite, etc

City

State

Zip Code

Country

Your Phone Number

Your Email

Emergency Contact

Name

Relationship to You

Phone Number

When is client generally available for an appointment? (Please list specific weekdays and the earliest time client is available on each day. We are open 9-8 Monday-Thursday and 9-5 on Friday.)

Family Information

Who does client currently live with? (Please list full names, ages, and each person's relationship to client.)

Family Marital Status

single

married

living together

divorced

separated

widowed

Client Concerns

What is the reason for seeking counseling for the client at this time? (Please be as detailed and specific as possible.)

How long has this been a concern? What prompted you to contact us now?

Any concerns for safety? Any current or past thoughts of self-harm or suicide? Any suicide attempts?

Any concerns with alcohol, drugs, or other addictions?

Treatment History

Any previous counseling?

Any previous psychiatric diagnoses or hospitalizations?

Is client currently taking any psychiatric medications for depression/anxiety/bipolar/ADHD, etc.?

Any general physical health issues?

Additional Information

How did you hear about us?

Has client been seen at MaineStay previously?

Yes

Is treatment court mandated?

Yes

What is your gross annual household income? (This will be used to determine session fee.)