Client's Name:
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Counselor's Name
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Agency
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Address
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City
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State

Zip Code

Phone
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Fax

Email

Client's previous positive employment experiences:

Client's previous positive volunteer experiences:

What are client's skills?

What are client's limitations?

Does client take medications?
Yes
No

If yes, what kind and what is their schedule?

What are the signs of missed medication?

What kinds of situations does client find stressful?

Will client work better in a group or alone?

What level of supervision does client require?

Does client have any violent tendencies?

Additional comments that would be helpful in client's placement: