Adult Intake Form. Date: Client Name: If you are unable to answer any of the questions below, please write DK (Don t Know) in the blank provided.
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1 Date: Client Name: Adult Intake Form DOB: If you are unable to answer any of the questions below, please write DK (Don t Know in the blank provided. ETHNICITY (optional: Caucasian African American Hispanic Native American Asian Bi/Multiracial Other: HOUSEHOLD Marital Status single, never married engaged months married years divorced years separated years divorce in process months live-in for years prior marriages (self Intimate Relationship never been in a serious relationship not currently in serious relationship currently in a serious relationship not currently looking for serious relationship Relationship Sati sfaction very satisfied satisfied somewhat satisfied dissatisfied very dissatisfied List all persons currently living in your household Name Age Sex Relationship to you List children and stepchildren not currently living in your household Name Age Sex Relationship to you Describe any past or current significant issues in intimate relationships : HISTORY FAMILY OF ORIGIN Present during Childhood: Mother Father Stepmother Stepfather Brother(s Sister(s Other: Present entire childhood: Present part of childhood: Not present at all: Parent s current marital status: Married to each other for years Separated for years Divorced for years Mother remarried times Father remarried times Mother involved with someone Father involved with someone Mother deceased for years (your age at mother s death: Father deceased for years (your age at father s death: Describe parents: Father: biological adoptive step other Full name: Occupation: Education: General health: Mother: biological adoptive step other Full name: Occupation: Education: General health: Family Attachment and Counseling Center of Minnesota, Inc C Minnetonka Blvd. Deephaven, MN tel: fax
2 Describe childhood family experience : outstanding home environment normal home environment chaotic home environment alcoholic/addicted parent(s poverty (serious financial problems witnessed or was aware of physical/ verbal/sexual abuse (circle all that apply Page 2 of 6 - Adult experienced physical/verbal/sexual abuse from others (circle all that apply Describe any abuse experienced in childhood : Other difficult ch ildhood experiences: Age of emancipation from home: Circumstances: Describe any past or current significant issues in other immediate family relationships: DEVELOPMENTAL HISTORY (check all that apply to your development Problems during mother s pregnancy: Birth: none normal delivery high blood pressure difficult delivery bed rest cesarean delivery alcohol use complications: drug use cigarette use other Birth weight: Infancy: feeding problems sleep problems toilet training problems colic other: Childhood health: lead poisoning (age: ear infections head injury (list age and describe: other significant injury (list age and describe: asthma (age diagnosed seizures (type and ages: hearing loss (age diagnosed and severity: impaired vision not corrected by lenses (age diagnosed: surgeries (ages and type: chronic, serious health problems: Delayed developmental milestones (check only those that were not reached at expected age: sitting engaging peers walking rolling over tolerating separation speaking standing toilet training riding bicycle Social interaction (check all that apply to you as a child: normal social interaction isolated self very shy dominated others inappropriate sex play had acting out friends other: Emotional/behavior problems (check all that apply to you as a child: drug use alcohol abuse stealing often sad violent temper disobedient distrustful hostile/angry impulsive indecisive immature hyperactive extreme worrier self-injurious acts fire-setting Intellectual/academic functioning (check all that apply to you as a child: normal intelligence mild retardation high intelligence moderate retardation special education from to for anxious easily distracted frequently daydreamed authority conflicts attention problems Current or highest education level:
3 SOCIO-ECONOMIC HISTORY (check all that apply Living situation: Employment: housing adequate employed and satisfied homeless employed but dissatisfied housing overcrowded unemployed dependent on others for coworker conflicts housing change jobs a lot housing dangerous/ disabled: deteriorating Financial situation: no current financial problems large indebtedness poverty impulsive spending relationship conflicts over finances Page 3 of 6 - Adult Social support system: supportive network few friends substance-use-based friends no friends distant from family of origin living companions dysfunctional Military history: never in military served in military: Legal history no legal problems now on parole/probation arrest(s not substance-related arrest(s substance-related court ordered this treatment jail/prison time(s; total time served: describe last legal difficulty: Sexual history : heterosexual orientation homosexual orientation bisexual orientation currently sexually active not currently sexually active currently sexually dissatisfied history of unsafe sex: ages to age first sexual experience: age first pregnancy or fatherhood: history of promiscuity: ages to Cultural/Spiritual/Recreational history: Cultural identity (e.g. ethnicity, religion: Describe any cultural issues that contribute to current problem: Yes No Active in community/recreational activities? Was active in community/recreational activities? Currently engage in hobbies? Currently participate in spiritual activities If answered yes to any of the above, describe: Name and city of church attended: Describe any other developmental problems or issues: MEDICAL AND PSYCHOLOGICAL HISTORY Primary Care Physician: ` Phone: Psychiatrist (if any: Phone: Describe current physical health: Good Fair Poor List any current medical conditions : List any known allergies: Describe any serious hospitalization or accidents. Include Date, Age, and Reason Have you previously taken medication to treat psychological problems? no yes (include below List any medications you currently take: Medication Reason Dosage Freq Start/End Date Physician Side Effects Beneficial? Which of the following areas of functioning have been impaired by psychological problems? (Check all that apply Occupational Academic Social Affective (Emotional Physical
4 Is there a history of any of the following in the family? tuberculosis mental retardation birth defects heart disease emotional problems high blood pressure behavior problems alcoholism thyroid problems drug abuse cancer diabetes Page 4 of 6 - Adult Alzheimer s disease or dementia stroke other chronic or serious health problems: Has any family member ever received a psychiatric diagnosis or psychological tre atment (inpatient or outpatient? No Yes (describe below Has any family member ever taken medication for a psychological problem? No Yes (describe below SUBSTANCE USE HISTORY (check all that apply Family alcohol/drug abuse history : father sibling(s mother spouse/significant other stepparent/live-in children uncle(s/aunt(s other grandparent(s Substance use status: no history of abuse active abuse early full remission sustained full remission sustained partial remission Issues related to substance abuse: hangovers assaults seizures binges blackouts job loss overdose arrests suicidal impulse sleep disturbance withdrawal symptoms medical conditions tolerance changes loss of control of amount used relationship conflicts Substances used: Alcohol amphetamines/speed barbiturates/owners caffeine cocaine crack cocaine hallucinogens (e.g, LSD heroin inhalants (e.g., glue, gas marijuana or hashish nicotine/cigarettes PCP prescription: other: First use age: Current use? (Yes/No Last use age: Frequency Amount PREVIOUS TREATMENT PSYCHIATRIC HOSPITALIZATIONS AND TREATMENT (INCLUDING CD TREATMENT Prior outpatient psychotherapy or counseling? No Yes If yes, complete the following : Age at time Psychotherapist/Counselor (Agency, City Duration Circumstances for treatment Are you currently seeing any of the above? No Yes If yes, please include name here:
5 Severe Moderate Mild None Severe Moderate Mild None Prior hospitalizations or inpatient treatment for psychological or CD issues? No Yes If yes, complete the following : Age at time Hospital/Treatment Center Duration Circumstances for treatment PREVIOUS DIAGNOSES Have you ever been diagnosed with a psychiatric, sub stance abuse, learning, emotional, or behavioral disorder?? No Yes If yes, complete the following : Diagnosis Age Diagnosis made by Agree? CURRENT SYMPTOM CHECKLIST (Rate the intensity of the symptoms present in the last two weeks None = This symptom is not present at this time Mild = This symptom is currently impacting my quality of life, but not significantly impairing my day-to-day functioning Moderate = This symptom is significantly impacting my quality of life and/or day-to-day functioning Severe = This symptom is profoundly impacting my quality of life and/or day-to-day functioning Symptom Symptom Depressed mood Low energy Sleep disturbances Dissociation Hyperactivity Bingeing Decreased sex drive Unresolved guilt Irritability Nausea/acid indigestion Social anxiety Self-mutilation/cutting Impulsive actions/speech Nightmares Elevated mood Losing train of thought Mood swings Disorganized Anorexia Social isolation Grief Phobias Headaches Loneliness Problems at Home Increased or decreased appetite Unplanned weight gain Unplanned weight loss Paranoid thoughts Poor concentration/indecisive Purging/over-exercising Excessive worrying Low self-worth Anger management problems Tension Hallucinations Racing thoughts Restlessness Loss of interest in normal activity Decreased creativity/productivity Unresolved anger Easily distracted Memories of trauma Hopelessness Marital problems Panic attacks Suicidal thoughts Feel panicky/anxious Work problems Has attempted suicide in the past Briefly describe how the above symptoms impair your ability to function :
6 ENVIRONMENTAL STRESSORS (check all that app ly and are current or recent Death of a family member Death or loss of a friend Health problems in family Inadequate social support Disruption of family by separation Living alone Disruption of family by divorce Difficulty with acculturation Disruption of family by estrangement Discrimination Marriage stress Adjustment to life cycle transition Removal from the home Illiteracy Remarriage of parent Academic problems Sexual abuse Discord with teachers or classmates Physical abuse Unemployment Parental overprotection Threat of job loss Neglect of a child Stressful work schedule Inadequate discipline Job dissatisfaction Discord with siblings Job change Birth of a sibling Discord with boss or coworkers Birth of a child Homelessness Page 6 of 6 - Adult Inadequate housing Unsafe neighborhood Discord with neighbors or landlord Extreme poverty Inadequate finances Insufficient welfare support Inadequate healthcare Inadequate health insurance Recent arrest or incarceration Involved in litigation Victim of a recent crime Exposure to war, disasters, or other hostilities Discord with counselor, social worker, physician or other caregiver Other PRESENTING PROBLEMS Please state your reasons for seeking therapy. For each problem please include any additional relevant inf ormation including the length of time this has been a problem Therapist use only
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: Personal Information Sex: [
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
Christina Pucel Counseling 416 W. Main St Monongahela, PA /
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
COUPLE S INTAKE PAPERWORK Separate forms to be completed by each party
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ADULT INTAKE FORM. Name
Welcome to Solace Counseling Associates. Please note that the information is important for your care. Please fill out forms as completely as possible and have them ready before your first counseling session.
Name: Date of Birth: Address. Why I came for this visit: Who lives with you? Occupation:
BARIATRIC ADULT PSYCHOLOGICAL HISTORY Name: Date of Birth: Address Why I came for this visit: Who lives with you? Occupation: [ ] Live alone [ ] Spouse [ ] Partner Education: [ ] High School [ ] Some College
CLIENT HISTORY CLIENT LEGAL NAME: CLIENT PREFERRED NAME:
CLIENT HISTORY CLIENT LEGAL NAME: DATE: CLIENT PREFERRED NAME: FAMILY & SOCIAL BACKGROUND Please list and describe your current family members (immediate, extended, adopted, etc.) and/or other members
Client Intake Form. Briefly describe the reason(s) you are seeking psychotherapy at this time:
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MINOR CLIENT HISTORY
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Intake Form. Presenting Problems and Concerns. When did it start and how does it affect you:
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Employment Information Client: Place Phone Spouse: Place Phone
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Adult Information Form Page 1
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