Client History - [Client Name/ID]

Date of Assessment: YYYY-MM-DD

1. Identifying Information

• Client Name:
• Date of Birth:
• Age:
• Gender Identity:
• Pronouns:
• Contact Information: (Phone, Email, Address - ensure privacy compliance)
• Marital Status:
• Occupation/Student Status:
• Referral Source:

2. Presenting Problem

• Primary Reason for Seeking Services: (In client's own words, if possible)
• Duration of Problem:
• Severity/Impact on Daily Functioning:
• Client's Goals for Therapy:

3. History of Presenting Problem

• Onset: When did this problem first begin?
• Triggers/Precipitating Factors: What seemed to bring it on or make it worse?
• Course/Progression: How has it changed over time?
• Previous Treatments/Interventions: (Therapy, medication, self-help, etc. - what worked/didn't work?)
• Coping Strategies Used:

4. Mental Health History

• Previous Diagnoses: (Formal or informal)
• Previous Psychiatric Hospitalizations: (Dates, reasons, duration)
• History of Suicidal Ideation/Attempts: (Details, plan, intent, past attempts, protective factors)
• History of Homicidal Ideation/Threats: (Details, plan, intent)
• Substance Use History: (Type, frequency, amount, last use, treatment history)
• Eating Disorder History:
• Trauma History: (Abuse, neglect, accidents, combat, etc.)

5. Medical History

• Current Medical Conditions:
• Past Significant Medical Issues:
• Current Medications: (Name, dosage, reason)
• Allergies:
• Reason for current/recent medical consultations:

6. Family History

• Family Structure/Composition:
• Mental Health Issues in Family Members: (Parents, siblings, extended family - e.g., depression, anxiety, substance use, psychosis)
• Physical Health Issues in Family Members:
• Relationship Dynamics with Family: (Supportive, conflictual, enmeshed, distant)
• Significant Childhood Experiences: (e.g., parental divorce, loss, significant moves)

7. Social History

• Education: (Highest level attained, academic performance, satisfaction)
• Employment History: (Job satisfaction, work environment, recent changes)
• Living Situation: (Housing, roommates, support system)
• Significant Relationships: (Romantic partners, close friends, support networks)
• Hobbies/Interests/Leisure Activities:
• Religious/Spiritual Beliefs: (Importance, practices)
• Cultural Background:

8. Risk Assessment Summary

• (Consolidated from above sections) Current risk level (low, moderate, high) for self-harm, harm to others, or other safety concerns.
• Protective Factors:

9. Clinical Impressions/Diagnostic Impressions (Optional - may be separate)

• Mental Status Examination (MSE) Findings: (Appearance, behavior, speech, mood, affect, thought process, thought content, perception, cognition, insight, judgment)
• DSM-5/ICD-11 Diagnostic Formulation:

10. Treatment Plan (Can evolve)

• Therapeutic Modality:
• Frequency/Duration of Sessions:
• Specific Goals & Objectives:
• Interventions:
• Progress Monitoring:

Notes: (Any additional relevant observations or information)