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Shana Williams, Psy.D.

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Virtual Practice Statement

+1 (954) 298-8774

Client Form

Dr. Shana Williams

Licensed Clinical Psychologist

440 Sawgrass Corporate Pkwy, Suite 106

Sunrise, Florida 33325

drshana.williams@gmail.com

Ph: (954) 298-8774 / VP: (954) 526-9858

Initial Client Interview

Identification

Name

Date of Birth

Address

Sex *

M

F

City/State/Zip

Phone

Place of Birth

VP

Email

Insurance

Marital Status

Single

Married

Divorced

Separated

Widowed

Other

Race

White

African American/Black

Hispanic

Caribbean

Asian

Other

Hearing Status

Hearing

Deaf

Hard of Hearing

Late Deafened

Description of Problem

Why are you here today?

What is your biggest problem?

How have you tried to solve your problem?

Family History

Mother's Name

Mother's Age

Mother's Job

Father's Name

Father's Age

Father's Job

How do you get along with parents?

How do you communicate with your parents?

Talk

Text

Sign

Speechread

Sisters and Brothers

Name

Age

Sex

M

F

Name

Age

Sex

M

F

Name

Age

Sex

M

F

Name

Age

Sex

M

F

How do you get along with your sisters & brothers?

How do you communicate with your sisters & brothers?

Talk

Text

Sign

Speechread

Who are you closest to in your family?

Who do you live with now?

Who lives in your home?

Are you married?

Yes

No

Spouse's Name

How long?

Spouse's Employment

Children

Name

Age

Sex

M

F

Name

Age

Sex

M

F

Name

Age

Sex

M

F

Name

Age

Sex

M

F

How do you get along with your children/spouse?

Education History

Are you in school now?

Yes

No

What school?

Did you repeat any grades?

List all schools you went to

Name of School

What grades

Grades

Date Graduated

Name of School

What grades

Grades

Date Graduated

Name of School

What grades

Grades

Date Graduated

Name of School

What grades

Grades

Date Graduated

Favorite subject in school?

Worst class in school?

Clubs/Activities?

Employment History

Are you working now?

Yes

No

Ever worked before?

Yes

No

Where do you work?

What jobs did you have in past?

What do you do?

Are you happy with your job and pay?

Monthly Income

What kind of job or training do you want for the future?

Medical History

Do you have any medical problems?

Are you taking any medication?

Name of medication

Reason for taking

Name of medication

Reason for taking

Name of medication

Reason for taking

Name of medication

Reason for taking

Do you have hearing loss?

Yes

No

Age of loss

‎

Deaf

Hard of hearing

Is anyone else in your family deaf/hard of hearing?

Yes

No

Who?

Do you wear hearing aids?

What is your preferred way to communicate?

Sign

Oral

Sign & Voice

Write

Speechread

Psychological History

Is there any history of mental health problems in you or your family?

Have you had mental health issues?

Previous Diagnosis

Yes

No

Previous Medication

Yes

No

Previous Psychotherapy

Yes

No

What?

What?

Why?

Have you ever tried to kill or hurt yourself?

Yes

No

Explain

Are you thinking about killing yourself or hurting yourself now?

Yes

No

Explain

Are you thinking about hurting another person?

Yes

No

Who?

Why?

Who do you talk to about your problems?

Alcohol/Drug History

Do you drink alcohol?

Yes

No

How much in one week?

Have you ever received treatment for drug/alcohol problems?

Yes

No

Explain

Do you use drugs?

Yes

No

Substance

Age of 1st use

Last use

Frequency

Current use

Substance

Age of 1st use

Last use

Frequency

Current use

Substance

Age of 1st use

Last use

Frequency

Current use

Legal History

Have you ever been arrested?

Yes

No

For what?

Hobbies/Interests

What do you enjoy doing?

How much do you get time to relax?

Who is your best friend?

Special Comments

Are there any stressors that are affecting you?

What do you want in your future?

What do you need to be successful?

Any comments for the therapist?

Let's Connect

Thanks for submitting!

Email: Drshana.williams@gmail.com

Phone: +1 (954) 298-8774

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