Private Practice Intake Paperwork for Psychological Services with Dr. Chantelle Pseekos
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1 1 Private Practice Intake Paperwork for Psychological Services with Dr. Chantelle Pseekos Name: Social Security Number: Date: Date of Birth: Residential Address: Preferred Phone Number: Secondary Phone Number: Address: Preferred Security Question for Encrypted Messages: Answer to Security Question: I consent to contact from Dr. Chantelle Pseekos through (check all that apply) , Preferred Phone Number, Secondary Phone Number, Residential Address. Signature: Date: Age: Disability Status (Physical, Learning; if Applicable): Gender/Gender Identity: Racial Background/Identity: Sexual Orientation/Identity: Spiritual/Religious Identity: Other Important Parts of Your Identity (Please Specify): Employment Location Name/Profession (if Applicable/Please Specify Full or Part-Time): University/College Name/Major (if Applicable/Please Specify Full or Part-Time): Emergency Contact Name: Emergency Contact Relationship to You/Phone Number:
2 2 Current Symptoms/Areas of Concern (Please Check All that Apply/Specify How Long Each Symptom has Occurred in Days/Weeks/Years): Sleep Disruption Eating Disruption Reduced Concentration Distractibility Difficulty Adjusting to New Life Circumstances Panic Attacks Avoidance of Social Activities Anxiety (Lasting 1 Hour or More) Intrusive/Unwanted/Obsessive Thoughts Depression (Lasting 3 Days or More) Loss of Interest in Previously Enjoyed Activities Hopelessness Anger Aggression Irritability Extreme Mood Swings (Do Not Check if Symptom Only Occurs with Family) Sexual Trauma/Violence Emotional/Psychological Trauma/Violence Physical Trauma/Violence Grief/Death of a Loved One Family Difficulties
3 3 Challenges Understanding Yourself Impaired Social Relationships Impaired Romantic Relationships Impaired Work Functioning Impaired Academic Functioning Thoughts of Suicide Thoughts of Harming Others Self-Harm Behaviors Alcohol Use (4 or More Drinks in One Day/Evening) Non-Prescription Drug Use Lack of Attention to Details Risky Behavior Impulsivity Concerns Related to a Partner s Infidelity Divorce Sexual Difficulties Trust Difficulties Worries that Others May Leave You Physical Symptoms (e.g., Migraines, Stomach Upset) Seeing/Hearing Things Others Cannot Paranoia/Believing Others Monitor You Dissociative Experiences (e.g., Time Seems Lost) Other Areas of Concern (Please Specify)
4 4 Previous Symptoms/Past Areas of Concern (Please Check All that Used to Apply/Specify How Long Each Symptom Occurred in Days/Weeks/Years): Sleep Disruption Eating Disruption Reduced Concentration Distractibility Difficulty Adjusting to New Life Circumstances Panic Attacks Avoidance of Social Activities Anxiety (Lasting 1 Hour or More) Intrusive/Unwanted/Obsessive Thoughts Depression (Lasting 3 Days or More) Loss of Interest in Previously Enjoyed Activities Hopelessness Anger Aggression Irritability Extreme Mood Swings (Do Not Check if Symptom Only Occurs with Family) Sexual Trauma/Violence Emotional/Psychological Trauma/Violence Physical Trauma/Violence Grief/Death of a Loved One Family Difficulties
5 5 Challenges Understanding Yourself Impaired Social Relationships Impaired Romantic Relationships Impaired Work Functioning Impaired Academic Functioning Thoughts of Suicide Thoughts of Harming Others Self-Harm Behaviors Alcohol Use (4 or More Drinks in One Day/Evening) Non-Prescription Drug Use Lack of Attention to Details Risky Behavior Impulsivity Concerns Related to a Partner s Infidelity Divorce Sexual Difficulties Trust Difficulties Worries that Others May Leave You Physical Symptoms (e.g., Migraines, Stomach Upset) Seeing/Hearing Things Others Cannot Paranoia/Believing Others Monitor You Dissociative Experiences (e.g., Time Seems Lost) Other Areas of Concern (Please Specify)
6 6 Goals, Treatment History, Insurance Information, Personal Strengths Primary Goal(s) for Psychological Services: Preferred Treatment Approach (e.g., Cognitive Behavioral, Mindfulness-Based, Emotion- Focused, etc., if Applicable): Name of Primary Physician: Name of Psychiatrist/Psychiatric Nurse (if Applicable): List of All Medications (including Frequency/Dosage): Name of Any Previous Counselors/Psychologists/Psychiatrists/Other Mental Health Providers/Facilities (if Applicable): Dates/Duration of Previous Mental Health Treatment Services (if Applicable): Reason for Ending Previous Mental Health Treatment Services (if Applicable): Most Beneficial Part of Previous Mental Health Treatment Services (if Applicable): Least Beneficial Part of Previous Mental Health Treatment Services (if Applicable): I am Open to (Please Check All that Apply): Individual Counseling Services Group Counseling Services Couples Counseling Services Preferred Duration of Treatment (e.g., 3 months): Insurance Information (if Applicable): Interests/Hobbies: Personal Strengths/Areas that You/Others in Your Life View as Positives about You: Referred By/Learned About this Private Practice Through:
Client s Name: Today s Date: Partner s Name (if being seen as a couple): Address, City, State, Zip: Home phone: Work phone: Cell phone:
Client s Name: Today s Date: Partner s Name (if being seen as a couple): Address, City, State, Zip: Home phone: Work phone: Cell phone: Private email address: Student? If yes, where and major? May we leave
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COUNSELING INTAKE FORM
COUNSELING INTAKE FORM Name Age Date Full Address Home Phone Work E-mail Work History Occupation How long? If presently unemployed, describe the situation Hobbies/Avocations Any past/present military service?
Name Last First Middle Date. Completed by: If not client, relationship to client: Reason for Seeking Counseling:
CLIENT HISTORY (PSYCHOLOGICAL, SOCIAL, PHYSICAL and SPIRITUAL) Name Last First Middle Date Completed by: If not client, relationship to client: Reason for Seeking Counseling: Sex: [ ] Male [ ] Female Place
CLIENT INTAKE FORM. Please describe your main reason(s) for seeking services at this time?
KARI KOKKO, MSW, RSW CLIENT INTAKE FORM Client Name: Please describe your main reason(s) for seeking services at this time? CURRENT RELATIONSHIP STATUS Single Common Law Separated Widowed Cohabitating
WHEN YOU RE WORRIED ABOUT A STUDENT
WHEN YOU RE WORRIED ABOUT A STUDENT a guide for MIT faculty Faculty members often are among the first to notice signs of distress in their students. Your unique perspective can play a crucial role in identifying
DEPRESSION. There are a couple of kinds, or forms. The most common are major depression and dysthymic disorder.
DEPRESSION OBJECTIVES: At the end of this class, you will be able to: 1.list and describe several kinds of depression, 2.discuss the signs of depression, and 3.relate the treatment of depression. INTRODUCTION
HERTFORDSHIRE PARTNERSHIP UNIVERSITY NHS FOUNDATION TRUST. Referral Criteria for Specialist Tier 3 CAMHS
Referral Criteria for Specialist Tier 3 CAMHS Specialist CAMHS provides mental health support, advice and guidance and treatment for Children and Young People with moderate or severe mental health difficulties,
Address: City/State/Zip: Home Phone: Cell: Pager: Work Phone: Employer/School: Emergency Contact: Phone:
Rock Landing Psychological Group Adult Client Information Please Print Name: Relationship Status: Single Married Domestic Partner Separated Divorced Widowed Date of Birth: Female Male Ethnicity: Address:
Nathan Driskell, MA, LPC, NCC
Nathan Driskell, MA, LPC, NCC https://nathandriskell.com New Client Questionnaire/Psychosocial History (To be completed by the client) Please complete this form to the extent that you feel comfortable.
Objectives. Common mental health disorders Facts about mental health Typical development How to help Resources.
Project Aware ACCESS Increase youth access to mental health services and supports within a data-based multi-tiered framework (e.g., ISF; Barrett, Eber, & Weist, 2013) AWARENESS Increase awareness of mental