1. SLP Counseling, Inc
Physical/Mental Health Information 304 1/2 East Main St
Client Name ___________________________________ Wilmore, KY 40390
Office Phone (859) 858-2619
Date of Birth __________________________________
Address ______________________________________ Home Phone (______)_________________
_______________________________________ Cell Phone (______)_________________
_______________________________________ Work Phone (______)_________________
E-mail _______________________________________
(The confidentiality of e-mail cannot be guaranteed.
Include your e-mail address if it is ok for me to use it.)
I grant permission for my therapist to call and leave a message
with people or on an answering machine/voicemail at the following numbers: Home phone Cell Phone Work Phone
Name of your general physician _______________________________ Phone number_______________________
Name of your other health care providers _______________________________ Phone number_______________________
_______________________________ Phone number_______________________
_______________________________ Phone number _______________________
Please describe any current health issues.
Have you ever taken any psychiatric medication? Y N Name of medications _________________________________________
__________________________________________
__________________________________________
Have you ever been hospitalized for a psychiatric issue? Y N Issue and date __________________________________________
__________________________________________
Are you currently using caffine recreational drugs alcohol prescription medications
Please list any current prescription medications you take and dosages:
Name of medication Dosage/times per day Date begun
_________________________ _______________________________ _______________
_________________________ _______________________________ _______________
_________________________ _______________________________ _______________