Personal Data

Family Restorations

Restoring the Soul of the Family for the Sake of the Kingdom
Dr. Kendra Klassen, Psy.D. ph. (949) 303-8933 mail. 23792 Rockfield Blvd. #290, Lake Forest, CA 92630
Personal Data
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Contact information
Full Name *

First Name Last Name Suffix
Date

- Month - Day Year
Gender

Male Female
Ethnicity

Caucasian African American Hispanic Asian

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Home Phone Number

- Area Code Phone Number
Work Phone Number

- Area Code Phone Number
Mobile Phone Number

- Area Code Phone Number
Please check boxes for phone numbers where it is okay for me to leave a message. *

Home Work Mobile
E-mail: *
Birth Date *

Month Day Year
Age *
Driver's License or State ID number
Highest grade completed

Grade school High School College/University Graduate School
Current occupation
Previous occupation
Person to contact in case of emergency *
Phone number of emergency contact *

- Area Code Phone Number
++Complete insurance information only if you plan on submitting for insurance reimbursement++
Insurance Provider
Group #
Insurance ID#
How did you find out about Dr. Klassen?

online search friend or family speaking event referral list pastor website
Name of any person who referred you
Are you interested in spirituality being a part of your therapy?

Yes No Not sure yet
The name of any church you attend regularly
What brings you to therapy now?
How serious would you rate this issue?
What would succesful therapy accomplish?
Marital Status
Marital Status

Single Dating Living together Married Separated Divorced Widow(er)
If living together
partners name
age
partner's age
date you moved in together

Month Day Year
If married:
spouses name
age
spouse's age
date of marriage

Month Day Year
If separated, date of marriage...

Month Day Year
...date of separation

Month Day Year
If divorced, date of marriage...

Month Day Year
...date of divorce

Month Day Year
If divorced more than once, how many prior marriages?
Children
Name
Age
Gender
Relation to you
living with you
Name
Age
Gender
Relation to you
living with you
Name
Age
Gender
Relation to you
living with you
Name
Age
Gender
Relation to you
living with you
Name
Age
Gender
Relation to you
living with you
Other adults living with you
name
Age
Gender
Relation to you
Other adults living with you
name
Age
Gender
Relation to you
Family History
Father
name
Age
Occupation
Mother
name
Age
Occupation
Did you grow up with both parents in the home?

Yes No
If not, what age were you when they divorced?
What was the custody arrangement?
Are these your biological parents?

Yes No
If not, please explain
Step father
name
Age
Occupation
Step mother
name
Age
Occupation
To whom did you feel closest growing up?

Mom Dad Step mom Step dad None
To whom do you feel closest now?

Mom Dad Step mom Step dad None
Describe your relationship with your father/ step father
Describe your relationship with your mother/ step mother
Sibling's name
Gender
Age
Relationship to you
Sibling's name
Gender
Age
Relationship to you
Sibling's name
Gender
Age
Relationship to you
Sibling's name
Gender
Age
Relationship to you
Sibling's name
Gender
Age
Relationship to you
Has any member of your family ever suffered from anything which could be described as an "emotional" or "psychological" problem?
Please mention any history of domestic violence, child abuse or sexual abuse in your family.
Please mention any history of alcohol or drug use in your family.
What time in your life has been the most difficult for you?

toddler/preschool grade school Jr. High High school early 20s 30s present
Describe the reason for that difficult time in your life?
Medical Information
Current weight
pounds
One year ago
pounds
Maximum weight
pounds
When?
Do you exercise regularly?

Yes No
How?

SLEEP PATTERNS

	Yes	No
Do you sleep well?
Easy to get to sleep?
Easy to stay asleep?

Average hours of sleep per night
What recreation do you enjoy?
Primary physician
name
Location
city
Date of last physical

- Month - Day Year

MEDICAL CONDITIONS

	Never	Seldom	Sometimes	Often
Insomnia
Loss of Appetite
Back Pain
Asthma
Headaches
Phobias/Fears
Nausea
Allergies
Nervousness
Loss of temper
Fatigue
Depression
High blood pressure
Constipation
Diarrhea
Over-eating
Mood swings
Self-harm behaviors
Hearing/seeing things that are not there

Please describe any other current medical contitions and how long you have experienced them.
Medication

MEDICATION HISTORY

	Never	Seldom	Sometimes	Often
Appetite suppressants
Pain relievers
Sedatives/Tranquilizers
Sleep aids
Stimulants
Blood pressure meds
Heart medicine
Vitamins

Current medication
medication name
Dose
Purpose
Current medication
medication name
Dose
Purpose
Current medication
medication name
Dose
Purpose
Current medication
medication name
Dose
Purpose
Current medication
medication name
Dose
Purpose
Current medication
medication name
Dose
Purpose
Substance use
Tobacco use
Frequency of use
Alcohol intake
Frequency of use
How much to you typically drink each time?
Marijuana use
frequency
Drug use
List illegal drugs and prescription medication used for non-medical purposes.
Please describe your history with the substances listed above or any others not listed
Prior therapy/counseling
Have you ever been in prior counseling/therapy?

yes No
Therapist name and location
Date/ Length of treatment
Please describe the reason for the therapy.
Was therapy succesful?

Yes No Not sure
Therapist name and location
Date/ Length of treatment
Please describe the reason for the therapy.
Was therapy succesful?

Yes No Not sure
Therapist name and location
Date/ Length of treatment
Please describe the reason for the therapy.
Was therapy succesful?

Yes No Not sure
Therapist name and location
Date/ Length of treatment
Please describe the reason for the therapy.
Was therapy succesful?

Yes No Not sure
Have you ever been hospitalized for psychiatric reasons?

yes no
If "yes", please describe the reason, date and length of stay.
Have you ever attempted suicide?

yes no
If "yes", please give the date and provide detail about the situation.
Additional information
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Dr. Kendra Klassen, Psy.D. ph. (949) 303-8933 mail. 23792 Rockfield Blvd. #290, Lake Forest, CA 92630

Contact information

Marital Status

Children

Family History

Medical Information

Medication

Substance use

Prior therapy/counseling

Additional information

Thank you for taking the time to complete this form. Please take one last look to make sure the information is correct, then click the "Submit Form" button below to securely send me this information.