NEW CLIENT INFORMATION FORM
Mountain Forest Wellness, LLC, Mori Montagne, BSN,MN, EFT-ADV
Please provide the following information and answer the questions below.
Client Information
Date: ____________
Name: _____________________________________________
Best Phone number to call: _________________________
Best time to call?_____________________
Is it okay to leave messages at this number? □ Yes □ No
E-Mail Address: ____________________________________________________________________
Mailing address (optional):_____________________________________________________________
________________________________________________________________________________
How long have you been living at this address? _________How many times have you moved in past 3 years?____
Occupation: ______________________________________
Date of Birth: ________________
For appointment scheduling, what are the best:
Times of day:________________________
Days of the week:_____________________
Relationship Status:
□ Never Married □ Married □ Domestic Partnership □ Divorced/Single □ Widowed []Prefer not to answer
Emergency Contact Information:
Name: ______________________________________________
Relationship: _________________________________________
Phone: ______________________________________________
Other helpful stuff...optional if preferred:
Please list the first names and relationships of the five most important people in your life:
1. _____________________________________________________________________
2. _____________________________________________________________________
3. _____________________________________________________________________
4. _____________________________________________________________________
5. _____________________________________________________________________
Do you have pets? □ Yes □ No
If yes, please list: _________________________________________________________
Education: ______________________________________________________________
How would you rate your overall physical health? □ Excellent □ Great □ Good □ Fair □ Poor
Do you have any sleep problems? □ Yes □ No
If yes, please describe:_____________________________________________________
Are you dealing with any past or current addictions? □ Yes □ No
If yes, please describe: ____________________________________________________
Have you had any issues with Depression, Anxiety, or ADD/ADHD (Attention Deficit Disorder/
Attention Deficit Hyperactivity Disorder)? □ Yes □ No
If yes, please describe:_____________________________________________________
Are you currently seeing a therapist? □ Yes □ No
If yes, please describe what issues you are addressing in therapy:
_________________________________________________________________________________
_________________________________________________________________________________
Are you currently taking any medications? □ Yes □ No
If yes, please list: _____________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Are you usually: □ Early □ On Time □ Running Late
Do you exercise regularly? □ Yes □ No
If yes, please describe what you do and how often:_______________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
How often are you on electronic devices (computer, phone,TV, social media, gaming platforms)
_________________________________________________________________________________
What are your favorite hobbies and sports?
_________________________________________________________________________________
_________________________________________________________________________________
What do you do for fun?
_________________________________________________________________________________
_________________________________________________________________________________
Do you have a religious or spiritual orientation?
_________________________________________________________________________________
_________________________________________________________________________________
When you treat yourself, what are things you like to do?
_________________________________________________________________________________
_________________________________________________________________________________
What is your idea of a perfect vacation?
_________________________________________________________________________________
_________________________________________________________________________________
How did you hear about me?
_________________________________________________________________________________
Copy and paste this form into link below, which is a secure and protected link. Fill out information before sending please. Your typed name in this format is considered a legal signature. If your prefer you can print and bring with you if we are seeing each other in person.