Christina Pucel Counseling 416 W. Main St Monongahela, PA /

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1 ADULT INTAKE Name: Gender: M F DOB: Address: City: State: Zip: Telephone: Home Mobile Highest Level Education: Occupation: Emergency Contact: Relationship: Phone: Referred by: Family Members: Name Gender Age Relationship to you Living with you? PRESENTING PROBLEM / REASON FOR SEEKING COUNSELING Please list the nature of your main problem(s) and a brief history of your complaint(s) from onset to present: Please list the goals you would like to accomplish in therapy. Name: Adult Intake Page 1

2 Depression Low Energy/Fatigue Low Self-esteem Poor Concentration Hopelessness Worthlessness Guilt Sleep Issues Loss of Appetite Overeating Grief/Loss Mood Swings Isolation/Withdrawal Apathy Stress Anxiety/Panic CHIEF COMPLAINT (Check All That Apply To You): Feeling that you are not real Things around you are not real Nightmares Unpleasant thoughts Anger/Frustration Easily Agitated/Annoyed Impulsive Behavior Argues/Blames Others Alcohol/Drug Abuse Prescription Abuse Laxative/Diuretic Abuse Emotional Abuse Issues Physical Abuse Issues Sexual Abuse Issues Spousal Abuse Issues Fear of going crazy Phobias Racing Thoughts Anorexia/Bulimia Excessive Behaviors Obsessions/Compulsions Can t hold onto an idea Delusions See things others don t Hearing Voices Not thinking clearly/confusion Sexual Problems Marital Problems Other Relationship Problems Career/Work problems COUNSELING HISTORY Have you had counseling services in the past? Yes No If yes, with whom & when Have you ever attempted suicide or homicide? Yes No If yes, how many times Are you currently feeling suicidal or homicidal? Yes No If yes, do you have a plan? Yes No If you have a plan, please describe: Do you have the means to carry out your plan? Yes No If yes, please explain: Have you received a psychiatric diagnosis in the last? Yes No If yes, what is the diagnosis and by whom? Name: Adult Intake Page 2

3 SOCIO-ECONOMIC HISTORY Relationship status: Sexual Orientation: Living situation: Employment: single engaged married separated divorced remarried committed relationship heterosexual orientation homosexual orientation bisexual orientation transgender housing adequate homeless housing overcrowded dependent on others housing dangerous living companions employed, satisfied employed, dissatisfied unemployed coworker conflicts supervisor conflicts unstable work history disabled widowed Financial Situation: Social Support System: Military History: Legal History: no current issues large indebtedness poverty or below impulsive spending relationship conflicts supportive network few friends substance-use-based no friends distant from family of origin never in military served in military honorable discharge served in military dishonorable discharge no legal problems on parole/probation nonsubstance-related arrest substance-related arrest court ordered treatment Cultural History: cultural identity (ethnicity): cultural issues contributing to current concerns Leisure History: Currently active in community/recreational activities? Yes No Formerly active in community/recreational activities? Yes No How is most of your free time occupied? SPIRITUAL/RELIGIOUS HISTORY Do you regularly attend a church, synagogue, or other religious institution? Yes No Describe your participation: What is the role of your spiritual or religious beliefs in your life? Name: Adult Intake Page 3

4 FAMILY HISTORY DESCRIBE YOUR CHILDHOOD FAMILY EXPERIENCE: Outstanding home environment Normal home environment Chaotic home environment Witnessed physical/verbal/sexual abuse toward others Experienced physical/verbal/sexual abuse from others Were there any special circumstances in your childhood? Has anyone in your family ever been treated or hospitalized for substance abuse, mental health issues, or psychiatric conditions? Yes No If yes, please describe: Have any of your family members or friends ever attempted or committed suicide? Yes No If yes, please describe: SUBSTANCE ABUSE HISTORY Substance use status: no history of abuse active abuse no active abuse/dependence in 1-11 months partial abuse/dependence in 1-11 months no active abuse/dependence in over 1 year partial abuse/dependence in over 1 year Family alcohol/drug abuse history: father stepparent/live-in mother uncle(s)/aunt(s) grandparent(s) spouse/significant other sibling(s) children Name: Adult Intake Page 4

5 MEDICAL HISTORY: Please check which of the following medical symptoms you have experienced in the Past (P) and/or Currently (C): P C P C P C P C P C Fainting Constipation Premenstrual Syndrome Back Pain Stroke Asthma Stomach Ailments Weight Problems Chest Pain Heart Disease Vomiting Ulcer Allergies Painful Joints Tuberculosis Dizziness Unusual Bleeding Diabetes Head Injury Birth Defects Headaches Skin Problems Cancer Pounding Heart Trouble Breathing Neck Pain HIV Positive High Blood Pressure Jaw/Dental Pain Chills/Hot Flashes Chronic Pain Hepatitis A/B/C Thyroid Problems Unconsciousness Tingling/ Numbness CURRENT MEDICATIONS Dosage Frequency CURRENT HEALTHCARE PROVIDERS Telephone Address PCP Psychiatrist Other Signature of Client: Date: Name: Adult Intake Page 5

6 GAD-7 (Use to indicate your answer) Over the last 2 weeks, how often have you been bothered by the following problems? Not at all Several More Than Half The Nearly Every Day 1. Feeling nervous, anxious or on edge 2. Not being able to stop or control worrying 3. Worrying too much about different things 4. Trouble relaxing 5. Being so restless that it is hard to sit still 6. Becoming easily annoyed or irritable 7.Feeling afraid as if something awful might happen Total Name: Adult Intake Page 6

7 PHQ-9 (Use to indicate your answer) Over the last 2 weeks, how often have you been bothered by the following problems? Not at all Several More Than Half The Nearly Every Day 1. Little interest or pleasure in doing things 2. Feeling down, depressed or hopeless 3. Trouble falling or staying asleep, or sleeping too much 4. Feeling tired or having little energy 5. Poor appetite or overeating 6. Feeling bad about yourself or that you are a failure or have let yourself or your family down 7. Trouble concentrating on things, such as reading the newspaper or watching television 8. Moving or speaking so slowly that other people could have noticed? Or the opposite being so fidgety or restless that you have been moving around a lot more than usual 9. Thoughts that you would be better off dead or hurting yourself in some way Total If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? (Use to indicate your answer) Not at all Difficult Somewhat Difficult Very Difficult Extremely Difficult Name: Adult Intake Page 7