Basic Information Basic Information Please enable JavaScript in your browser to complete this form.SUMRAH JAN, LMFT Licensed Marriage and Family Therapist#97197 925-338-7526 Client Information Date *Name *Date Of Birth *Address *Address Line 1CityState / Province / RegionPostal CodeHome Phone: Cell Phone: *Work Phone: *Is it OK to leave a message? Yes NoAt which number(s)?Email address: *Do you check this often?Yes NoDo I have permission to contact you via email/text concerning appointments? *Yes NoOccupation: Social Security Number: Emergency Contact and Phone Number: *Relationship to Client: *Referred By: *-------------------------------------------------------------------------------Spouse/Partner Name: Age: Marital Status: Do you have children? YesNoIf yes, please list names/ages, gender: If client is a minor please complete this section:Your name and relationship to minor: Who does the child reside with? Contact information of other parent if relevant: Name: Home Phone: Work Phone: Cell Phone: Address: Child’s cell phone (if relevant): For Therapist To Fill Out: Tx Started Date MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Tx Termination Date MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Fee $Type of Tx: Reason for Termination: Physician’s Name: Phone: Date of Last Physical Exam: Describe your overall health today: *Health concerns (problems, major operations, illnesses or injuries: Why are you seeking treatment at this time? *What would you like to accomplish in counseling? *Have you received counseling in the past? *When and for how long? *What was the focus of the counseling? *Name of therapist(s) and phone number(s): *Have you ever been hospitalized or prescribed medicine for mental health reasons? If yes, please indicate when and where. *Have you ever attempted suicide? *When? *Describe the circumstances that lead to that event: Are you currently taking any prescription medicationsDo you smoke? How much and for how long?On average, how much alcohol do you consume in a weekDo you currently use any illegal drugs? Have you in the past? Please describe your use: Have you had or are you currently involved in any legal problems? Have you ever been a victim of a crime? Interests or hobbies: Submit