Global Counseling Associates


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625 Main St. #23 Windermere, FL 34786 407-405-5514

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Client Assessment Questionnaire

You must completely fill out the form below so we can better service your needs.

I AGREE to the Informed Consent below: You MUST completely agree to all statements below in this informed consent before any therapy sessions can begin. I have considered, understand, and agree to the risks, benefits, and alternatives to the use of email and other forms of online communication in clinical work with my treatment provider Global Counseling Associates. I understand that every effort will be made to maintain the confidentiality of our communications, including but not limited to secure storage of both paper and electronic files according to professional standards. I understand that I can choose to conduct email correspondence by regular email or by secure email on request, and that Global Counseling Associates can guarantee the confidentiality of secure email only on their end of the communication. I understand that no communication on the Internet can be guaranteed completely free from potential breach of confidentiality in transit by hackers or Internet service providers or by others who had access to the account or the computer. I TAKE FULL RESPONSIBILITY FOR THE SECURITY OF TREATMENT RECORDS ON MY OWN COMPUTER AND IN MY OWN PHYSICAL LOCATION. Global Counseling Associates will not be held liable for any breach of confidentiality regarding electronic or paper records taking place on my end. Global Counseling Associates have fully disclosed their professional credentials, which are available on this website. IF I AM CURRENTLY CONSIDERING OR THREATENING SUICIDE OR ANY FORM OF HARM TO MYSELF OR OTHERS, I TAKE FULL RESPONSIBILITY FOR SEEKING APPROPRIATE HELP IMMEDIATELY AND FOR ANY ACTION I MAY TAKE. I understand that information on nationwide crisis intervention and help resources in the United States includes the following: www.hopeline.com 1-800-SUICIDE 1-800-656-HOPE 1-800-TLC-TEEN All Global Counseling Associates have fully disclosed their professional credentials, which are available on this website. They have made it clear that they are licensed for independent practice as a licensed mental health professional in their state of residency. If my state of residence has laws regulating with whom I may seek counseling or therapy online, I am responsible for informing myself and my therapist and complying with such laws. I accept full responsibility for my decision to work with Global Counseling Associates under these conditions.
Select your Therapist:
Patient Full Name
Date of Birth
Age
Gender	Male Female
Social Security #
Phone	Email
Marital Status
Address Street City	State Zip
Insurance Information
Full Name of Insured
Social Security # of Insured
Insured's Date of Birth
Insured's Address (if different) Street 1 Street 2	City State Zip
Insured's Phone Number (if different)
Insured's Employer
Name of Insurance carrier for Mental/Behavioral Health Benefits
Complete Address for Mental/Behavioral Health claims
Phone Number for Mental/Behavioral Health claims
Insurance ID number
Co-pay amount (if known)
Deductible amount (if known)


Immediate Family Members

Employer
Occupation
School(s) (for children, and adults when applicable)
Referral Source
Chief Complaint
History of Present Illness: (include precipitating event(s), job/school/living situation, etc.)
Current Symptoms
Previous Treatment History: (dates of treatment or hospitalization, clinician names, interventions & response to treatment, etc.)
Any previous suicide attempts?	Yes No
Past Psychiatric Medications: (include names, dosages, when taken, who prescribed, and response)
Substance Use History: (include age of onset, history and current use or denial of use, consequences of use)	Alcohol Drugs Nicotine Caffeine
Medical History
Past or current history and/or treatment of	Stroke Seizures Migraines Liver Damage Thyroid Problems Anemia Diabetes Chronic Pain Chronic Fatigue Urinary Tract Infection Asthma Hepatitis Tuberculosis Eating Disorder Persistent flu-like symptoms Cancer Hypertension Cardiac Problems Communicable Diseases
Children: Prenatal events, Childhood diseases, Vaccination History
Current medications: (prescriptions/OTC/vitamins/herbal supplements)
Physical exam in the last year?	Yes No
Name of Primary Care Physician	Phone number:
Consent for Release to Communicate with PCP?	Yes No (If "No," please state reason for refusal
I have reviewed the Practice's Notice and Privacy Practices and understand that my protected health information may be used by the Practice as described in the notice.	Yes No
Food or drug allergies? If yes, nature of reaction:	Yes No
Family History: (psychiatric history, substance abuse history, suicide and homicide of family members, history of abuse)
Psychosocial History: (social/cultural/spiritual factors and support, education and job history, legal history, sexual orientation, utilization of community resources, significant childhood events) Children/Adolescents: include developmental history and educational history:
Marriage/Family: (marital history, including current/prior marriages/significant relationships; names/relationships with children
Interests & Activities
Strengths & Weaknesses: