Neurobiopsychosocial History
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- Nickolas Owens
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1 Neurobiopsychosocial History Name: Date: DOB: Information provided by: A. Reason for seeking services: Referred by: Concerns, from the referral source s perspective: Concerns, from your perspective (if different): Concerns, from the perspective of others: B. Family history: Your parents relationship with each other: Your relationship with each parent growing up (list three adjectives that describe the nature of the relationship): Your relationship with each parent, as of today (list three adjectives that describe the nature of the relationship): Your parents problems with physical health, substance use, or mental health: I am the oldest child middle child youngest child only child Your relationship with your siblings (list three adjectives that describe the nature of the relationship): Other important family members to you:
2 C. Cultural background: I belong/self-identify with the following cultural groups: race/ethnicity sexual orientation gender religion (include any others here) D. Symptoms: During the past two weeks, mark an X in the appropriate column for how much (or how often) you been bothered by the following problems. Problem Little interest or pleasure in doing things? Feeling down, depressed, or hopeless? Feeling more irritated, grouchy, or angry than usual? Sleeping less than usual, but still have a lot of energy? Starting lots more projects than usual or doing more risky things than usual? Feeling nervous, anxious, frightened, worried, or on edge? Feeling panic or being frightened? Avoiding situations that make you anxious? Unexplained aches and pains (e.g., head, back, joints, abdomen, legs)? Feeling that your illnesses are not being taken seriously enough? Thoughts of actually hurting yourself? Hearing things other people couldn t hear, such as voices even when no one was around? Feeling that someone could hear your thoughts, or that you could hear what another person was thinking? Problems with sleep that affected your sleep quality over all? Problems with memory (e.g., learning new information) or with location (e.g., finding your way home)? Unpleasant thoughts, urges, or images that repeatedly enter your mind? Feeling driven to perform certain behaviors or None (not at all) Slight (rare, a day or two) Mild (several days) Moderate (more than half the days) Severe (nearly every day)
3 mental acts over and over again? Feeling detached or distant from yourself, your body, your physical surroundings, or your memories? Not knowing who you really are or what you want out of life? Not feeling close to other people or enjoying your relationships with them? Drinking at least 4 drinks of any kind of alcohol in a single day? Using any of the following medicines without a doctor s prescription, in greater amounts or longer than prescribed: painkillers (like Vicodin), stimulants (like Adderall), sedatives (like Ambien or Valium)? Using drugs like marijuana, cocaine or crack, club drugs like ecstasy, hallucinogens like LSD, heroin, inhalants or solvents like glue, or methamphetamine (speed)? Table taken from DSM-5 Level 1 Cross-Cutting Symptom Measure. Eating patterns (e.g., detail typical eating frequency, amount, self-reported eating too much, not enough, feeling out of control while eating, feeling guilt after eating, etc.): Physical activity (e.g., amount and type of physical movement in an average day): E. Coping strategies: How do you usually cope with these symptoms? Which people in your life support you? F. History of medical conditions and treatment: Provider Date Diagnosis Treatment Results
4 G. History of mental health treatment (counseling and/or medication): Provider Date Diagnosis Treatment Results H. Developmental history: Prenatal issues Developmental delays Parental divorce Grief/loss Any other notable details about developmental history: Experiences of abuse: Your age at the time Kind of abuse* Approximate dates when abuse occurred By whom? Whom did you tell? Effect of telling? * i.e., physical abuse, sexual abuse, psychological abuse, neglect
5
6 I. Current living situation: Current partner: Length of relationship: People living in the home: Relationship Name Age Occupation Any problems? Own home Rent house Rent apartment Financial Stressors Moves: Location Year Reason for move J. Occupational/Educational History: Top 3 occupational/educational problems or issues: If still in K-12 grades: repeated a grade suspended expelled moved schools advanced/gifted classes special education/disability services IEP 504 plan If completed K-12 schooling: highest education level completed High School: currently attending dropped out completed/graduated GED Undergraduate: currently attending dropped out completed/graduated Degree: College:
7 Graduate: currently attending dropped out completed/graduated Degree: College: What are your occupational or educational goals? [If adolescent] Post-high school goals: [If adult] Career goals: Work history: Position Company Dates Reason for leaving K. Legal history: Current/pending legal charges: Past legal charges: Convictions: misdemeanor felony Incarceration record: Conviction Year Length of sentence
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