Patient Information Sheet

Last Name _________________________ First ___________________________ Middle __________________

Address __________________________________ City ______________________ State ________ Zip _____________
Birthdate ______/______/______

Sex ______M ______F

Social Security # _______ - _______ - _______

Marital Status ____________________________

E-Mail Address ___________________________________________

Home Phone # (______) __________-____________

May we leave a message?

YES

NO

Cell Phone # (______) __________-____________

May we leave a message?

YES

NO

Work Phone # (______) __________-____________

May we leave a message?

YES

NO

Employer: ________________________________________ Address: ________________________________________

Referred by ______________________________________________________________________________________
Emergency information
If some kind of emergency arises and we cannot reach you directly, or we need to reach someone close to you, whom
should we call?
Name: ___________________________________ Phone: ____________________ Relationship: _________________
Address: _________________________________________________________________________________________
Significant other/nearest friend or relative not residing with you: _____________________________________________
Financially Responsible Party (if not the patient)
Name: ___________________________ Relationship: ________________________SS#: ________________________
Address:________________________________ City: ________________________ State: _______ Zip Code: _______
Home #: _________________________Cell #: __________________________ Work # _________________________
Patient request for email communication
Communication over the Internet and /or using the email system are not encrypted and are inherently insecure. There is no
assurance of confidentiality of information when communicated this way. Nevertheless, you may request that we
communicate with you via email. To do so, you must agree on the following terms and conditions.
1. This request only to Pathway Counseling, LLC
2. Pathway Counseling LLC, will not communicate health information that is specifically proceed under state and
federal law (e.g. HIV/AIDS information, substance abuse records information, mental health information) via
email even if we agree to communicate with you via email.
Please specify the email address to which communication should be addressed:_________________________________
I certify the email address provided on the Request is accurate, and that I or my designee on my behalf accept full
responsibility for messages sent to or from this address. I acknowledge that I have received a copy of the Important
Information About Provider/patient Email form, and I have read and understand it. I understand and acknowledge that
communication over the Internet and/or using the email system are not encrypted and are inherently insecure; that there is
no assurance of confidentiality of information when communicated this way. I agree to hold Pathfinders Counseling LLC,
and individuals associated with it harmless from any all claims and liabilities rising from or related to the Request to
communicate via email.
____________________________________
Signature of patient or person representative
behalf of patient

______
Date

_____________________________________________
If personal representative \,authority to act on

Pathfinders Counseling, LLC

Name:_____________________________

10979 Reed Hartman Highway Suite 136B

Phone #: (513) 719-PATH
Fax #(513) 719-9222

Case ID#__________________________

ADULT ASSESSMENT
Date:

_____________________

What concerns brought you to counseling: _______________________________________________________________

__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

HEALTH HISTORY:
Do you have any drug/food allergies?

Yes No

If yes, please specify:

__________________________________________________________________________________________________
Do you have any physical health problem(s)?

Yes No

If yes, what condition(s):

__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Tobacco products use Packs per day _______

Current
Past
Never Used
Other Tobacco Product Use: ______________________

Weight change in the past 6 months:

Yes
Significant appetite change over the past month:

No
Yes

Amount: ______
No

Are you currently on any physician-prescribed medications or regularly take any over the counter medication, including
any prescriptions for anxiety, depression or other mental conditions?
Yes No
If yes, please list all medications below.
Medication/Purpose

Dosage/Times Per Day

How Long?

In the past, have you taken medication for a mental health condition?

Do you take this medication consistently?

Yes
No
Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

If yes, please describe:

__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

Name:_____________________________

Pathfinders Counseling, LLC

Case ID#__________________________

10979 Reed Hartman Highway Suite 136B

Phone #: (513) 719-PATH
Fax #(513) 719-9222

BEHAVIORAL HEALTH:
Have you had prior mental health services, counseling, or alcohol/drug treatment?
If yes, please list names and dates below:
OUTPATIENT
THERAPIST OR PROGRAM NAME

Yes No

INPATIENT
DATE

HOSPITAL

Is there any history of emotional or mental problems in the family?

DATE

Yes No

If yes, please explain:________________________________________________________________________________

__________________________________________________________________________________________________
Has anyone in your family had problems with alcohol or other drug use?

Yes No

If yes, please explain:________________________________________________________________________________

__________________________________________________________________________________________________
Have you ever experienced:
Physical abuse
Rape/sexual assault
Sexual abuse
Domestic violence

Emotional abuse
Other significant trauma

Please comment:____________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
CULTURAL/ETHNIC/SEXUAL/SPIRITUAL:
Cultural/ethnic/racial issues that need consideration:________________________________________________________
Sexual orientation issues that need consideration:__________________________________________________________
Religious/spiritual issues that need consideration:__________________________________________________________
LEGAL
Do you have any current pending legal charges? Yes No

If Yes, explain____________________________________________________________________________________
Client Signature___________________________________________________

Date

_____________

Reviewed/Completed by Clinician

________________________________

Date

_____________

_____________________________________________

Date

_____________

Reviewed/Updated