Please check all the behaviors and symptoms that you consider problematic:
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- Barry Cameron
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1 Name Date Address Phone # Date of birth address Social Security Describe the issue that brought you here today: Please check all the behaviors and symptoms that you consider problematic: Distractibility Change in appetite Suspicion/paranoia Hyperactivity Lack of Motivation Racing thoughts Impulsivity Social withdrawal Excessive energy Anxiety/worry Mood swings Phobias Poor memory/confusion Panic attacks Sleep problems Seasonal mood changes Nightmares Fatigue Sadness/ Depression Social discomfort Eating problems Loss of pleasure/interests Obsessive thoughts Gambling problems Hopelessness Compulsive behaviors Computer addiction Thoughts of death Aggression/fights Problems with pornography Self-harm behaviors Frequent arguments Parenting problems Suicidal thoughts Irritability/anger Sexual problems Loneliness Homicidal thoughts Relationship problems Low self-worth Flashbacks Work/school problems Guilt/shame Hearing voices Alcohol/drug use Crying spells Visual hallucinations Other Additional symptoms or behaviors that you are concerned about. Explanation of Other:
2 Have you ever had thoughts, made statements, or attempts to hurt yourself, if yes, please describe: Have you ever had thoughts, made statements, or attempted to hurt someone, if yes, please describe: Have you recently been physically hurt or threatened by someone else, if yes, please describe: Previous Mental Health Treatment: Type of Treatment When Provider/Program Reason for Treatment Outpatient Counseling Psychiatric Mediation Psychiatric Hospitalization Drug/Alcohol Treatment Self-help/Support Groups
3 Substance Abuse History: Current Use (last 6 months) Past Use Substance Yes No Frequency/Amount Yes No Frequency/Amount Tobacco Caffeine Alcohol Marijuana Cocaine/Crack Ecstasy Heroin Inhalants Meth Pain Pills PCP/LSD Steroids Tranquilizers Did you have any problems (legal, work, etc.) as a result of using a substance? If yes, please describe.
4 Medical Information: Date of last physical exam: Physician: Please list any CURRENT medications: Have you had any allergic reactions to medications? If yes, please describe. Have you had any surgical procedures? If yes, please describe. Have you experienced any of the following medical conditions? Seasonal Allergies Asthma Headaches Stomach aches Chronic pain Dizziness Fainting Serious accidents Head injury Seizures Diabetes Sleep problems Vision problems Cancer Other
5 Family/Social/Interpersonal History: Relationship Name Age Quality of Relationship Mental Health Problem Mother: Father: Stepmother: Stepfather: Siblings: Other Relatives Where were you born? Where were you raised? How would you describe your childhood? How were you disciplined?
6 Is there anything that happened when you were younger that bothers you today? Are you currently married? yes no Spouse name Divorced? yes no In a relationship? yes no Have you ever been married, if yes, how many times and how old were you when you got married? Do you have any children? yes no What are their names and ages? Are you currently satisfied with these relationships? Developmental History Birth weight Full term baby or premature What do you know about mother s labor and delivery? Did you meet developmental milestones at the expected ages?
7 Trauma History: Have you experienced or witnessed the following traumatic events? Tornado Hurricane Car Accident Robbery Other (please explain) Have you experienced/witnessed physical abuse, if yes, please describe the nature and the relationship with the abuser. Have you experienced/witnessed sexual abuse, if yes, please describe the nature and the relationship with the abuser.
8 Employment/Education/Military/Legal Information: Please tell me about your social support network (spouse, partner, family, friends, co-workers, support groups, religious/spiritual). Employment: Current Employer Position: Length of time in this position Stress level in this position: Low Medium High Past Employers Why did you leave past employers? Education: Are you currently attending school? Yes No What is the highest grade you have completed? Did you graduate high school? Yes No Any college? Yes No Did you have any difficulties in school (behavioral, learning), if yes, please describe below. Military Service: Have you been/are you currently in the military? (if no, skip this section). Branch Date of Discharge Type of Discharge Rank Were you in combat?
9 Legal History: Have you ever been convicted of a felony? No If yes, please describe below Are you currently on probation or parole? No if yes, please describe below If you are experiencing difficulties in any of the above areas, please describe below. And finally What do you like about yourself? Please tell me about your strengths and talents. What do you like to do for fun? (Hobbies, books, sports) What would you like to have better or different as a result of counseling? Thank you for taking the time to provide me with this information.
CLIENT INFORMATION FORM. Name: Date: Address: Gender: City: State: Zip: Date of Birth: Social Security Number:
Name: Address: Gender: City: State: Zip: Date of Birth: Social Security Number: Contact Telephone Numbers Please complete relevant information and indicate the number at which you wish to be contacted
Demographic Information Form
PATIENT INFORMATION Demographic Information Form / / Mailing: Male Female SSN#: - - Home Cell Relationship Status (circle one): Single / Married / Divorced / Widowed / Other: ( ) - ( ) - (Preferred Phone
*Please complete this form and bring to your first appointment. This information is fundamental to the assessment and treatment process.
*Please complete this form and bring to your first appointment. This information is fundamental to the assessment and treatment process. PATIENT CONTACT INFORMATION Name Age Date of birth Phone ( ) Mailing
Demographic Information Form
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Intake Form. Presenting Problems and Concerns. When did it start and how does it affect you:
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Adult Intake Form. Name: Date: Describe the problem that brought you here today: Briefly share relevant history behind this problem:
Adult Intake Form Date: Describe the problem that brought you here today: Briefly share relevant history behind this problem: Check any of the following symptoms that you are experiencing: Distractibility
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Adult Information Form Page 1
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Adult Information Form
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