COUPLE S INTAKE PAPERWORK Separate forms to be completed by each party

Transcription

1 -S, BCN 5604 Wesley Street, Suite 103; Greenville, TX Phone: ; COUPLE S INTAKE PAPERWORK Separate forms to be completed by each party Client s name: Date: Gender: F M Date of birth: Age: SSN: Form completed by If you need more space for the following questions, please use the back of the sheet. Primary reason(s) for seeking services: Anger management Anxiety Coping Depression Addictive behaviors Fear/phobias Mental confusion Sexual concerns Sleeping problems Eating disorder Alcohol/drugs Hyperactivity Other mental health concerns (specify): EMOTIONAL/PSYCHIATRIC TREATMENT HISTORY Information about (past and present): Reaction or Yes No When Where overall experience Counseling/Psychiatric: Treatment: Suicidal thoughts/attempts: Drug/alcohol treatment: Hospitalization: Diagnosis Treatment Beneficial? Has a family member had outpatient psychotherapy? Yes No If yes, who/why (list all): Current prescribed medications Dose Dates Purpose Side Effects Current over-the-counter meds Dose Dates Purpose Side Effects Has any family member used psychotropic medications? Yes No If yes, who/why (list all):

2 -S, BCN 5604 Wesley Street, Suite 103; Greenville, TX Phone: ; Behavioral/Emotional Please check any of the following that are typical for you: Affectionate Aggressive Alcohol Problems Angry Anxiety Blinking, Jerking Bizarre Behavior Careless, Reckless Chest Pains Clumsy Cooperative Confident Cyber Addiction Depression Destructive Difficulty Speaking Dizziness Drugs Dependence Eating Disorder Enthusiastic Excessive Masturbation Expects Failure Fatigue Fearful Frequent Injuries Frustrated Easily Gambling Generous Hallucinations Heart Problems Hopelessness Hurts Animals Irritable Impulsive Lazy Lies Frequently Listens to Reason Loner Low Self-Esteem Messy Moody Often Sick Over Active Over Weight Panic Attacks Phobias Poor Appetite Psychiatric Problems Sad Selfish Sexual Addiction Sick Often Short Attention Span Shy, Timid Sleeping Problems Slow Moving Speech Problems Suicidal Threats Suicidal Attempts Teeth Grinding Tics or Twitching Unsafe Behaviors Unusual Thinking Weight Loss Withdrawn Worries Excessively Other: Please describe any of the above (or other) concerns: Medical/Physical Health (check all that apply to your health) Abortion Anemia Asthma Blackouts Blindness Bronchitis Cerebral Palsy Chicken Pox Congenital Problems Croup Cancer Deafness Diabetes Diphtheria Dizziness Ear Aches Ear Infections Eczema Encephalitis Fevers Glandular Problems Heart Diseases High Blood Pressure Kidney Disease Mental Illness Migraines Multiple Sclerosis Mental Retardation Muscular Dystrophy Nervousness Perceptual Motor Disorder Seizures Spinal Bifida Suicide

3 List any current health concerns: List any recent health or physical changes: Describe any serious hospitalizations or accidents: Date Age Reason Nutrition (Define your current nutritional status) Do you eat Breakfast, Lunch, Dinner, Snacks? Yes Would you consider your food choices healthy? Yes No No Do you have any issues relating to nutrition? Yes No Please explain: Most Recent Examinations (Define any concerns, problems, issues) Type of Examination Date of Most Recent Visit Results Physical Examination: Dental Examination: Vision Examination: Hearing Examination: CHILDHOOD (Check corresponding boxes defining your childhood experience) Present entire childhood: Mother Father Stepmother Stepfather Brother(s) Sister(s) Other (specify) Present part of childhood: Mother Father Stepmother Stepfather Brother(s) Sister(s) Other (specify) Not present at all: Mother Father Stepmother Stepfather Brother(s) Sister(s) Other (specify)

4 Parent s History: Current marital status: Married to each other for years; Separated for years Divorced for years; Please Explain: Describe parents: Father deceased for years, age of client at father s death Father Occupation Education Level General Health Father remarried times Father involved with someone else Your relationship with parent Poor Average Good; Please Explain: Mother deceased for years, age of client at mother s death Mother Occupation Education Level General Health Mother remarried times; Mother involved with someone else Your relationship with parent Poor Average Good; Please Explain: Describe childhood family experience: Outstanding Home Environment Normal Home Environment Chaotic Home Environment Witnessed physical/verbal/sexual abuse toward others Witnessed physical/verbal/sexual abuse from others Age of emancipation from home: Circumstances: Special circumstances in Childhood: IMMEDIATE FAMILY/ RELATIONSHIPS(Describe your family situation and living arrangements) Relationship Status: Never been in serious relationship Not currently in relationship Currently in serious relationship Martial Status: Single, never married; Engaged months Married for years; Divorced for years; Separated for years Divorce in process months; Live-in for years; Prior marriages self partner

5 Relationship Satisfaction: Very satisfied with relationship Satisfied Somewhat satisfied Somewhat dissatisfied Dissatisfied Very dissatisfied with relationship Describe any past or current significant issues in intimate relationships: IMMEDIATE FAMILY CONTINUED List all persons/family members living in client s household: Name Relationship Quality of Relationship Family member Age Gender (e.g., grandparent, cousin, foster child) with the Client Others living in the household Relationship (e.g., grandparent, cousin, foster child) Describe any past or current significant issues in other immediate family relationships: Comments:

6 FAMILY MEDICAL HISTORY (Check all that apply for client) Is there a history of any of the following in the family: Tuberculosis Birth Defects Emotional Problems Diabetes Behavior Problems Thyroid Problems Cancer Mental Retardation Heart Disease Stroke Alcoholism Drug Abuse Alzheimer s Disease/Dementia Other: SUBSTANCE USE HISTORY (Check all that apply for client) Family alcohol/drug abuse history: Father Mother Grandparent(s) - Sibling(s) Stepparent/live-in Uncle(s)/Aunt(s) Spouse/Significant Other Children Other Describe: Client s Substance use status: No history of abuse Active abuse Early full remission Early partial remission Sustained full remission Sustained partial remission Clients Treatment history: Outpatient (ages[s] ) Inpatient (age[s] ) 12-step program (age[s] ) Stopped on own (age[s] ) Describe Consequences of substance use (check all that apply): Hangovers Seizures Medication complications Tolerance changes Relationship conflicts Job loss Blackouts Loss of control amount used Arrest Overdose Binges Withdrawal symptoms Sleep disturbance Assaults Suicidal impulse Other: Substances used (list all):

7 SOCIO-ECONOMIC HISTORY (Check all that apply) Living Situation: Housing adequate Homeless Housing crowded Dependent on others for housing Housing dangerous/deteriorating Living companions dysfunctional Employment: Where employed Employed and satisfied Employed but dissatisfied Unemployed Coworker conflicts Supervisor conflict Unstable work history Disabled (describe) Feelings about Work: Anxious Passive Enthusiastic Fearful Eager No Expression Bored Rebellious Other (describe): Financial Situation: No current financial problems Large indebtedness Poverty or below-poverty income Impulsive spending Relationship conflicts over finances Other(Describe) Social Support System: Supportive network Few friends Substance-use-based-friends No friends Distant from family of origin Military History: Never in military Served in military-no incident Served in military with incident Describe Legal History: No legal problems Now on parole/probation Arrest(s) not substance-related Arrest(s) substance-related Court ordered this treatment Jail/prison times, total time served: Describe last legal difficulty:

8 Leisure Recreational Ruth Whitely PhD, NCC, LPC Describe special areas of interest or hobbies (e.g. art, books, crafts, physical fitness, sports, outdoor activities, church activities, walking, exercising, diet/health, hunting, fishing, bowling) Activity How often now? How often in the past? (weekly, none, ect) (weekly, none, ect) What activities do you do with your significant other? How important are these activities to you? What issues do you wish to work on in counseling? What are your goals for therapy? Which issue is the most important to you?

9 What do you find yourself having the most difficulty with? How do you cope with this? What are two or three things you expect from your significant other? What must you get from him/her to be happy? What are one or two things about yourself would you like to change or think you need to change? How do you argue? How do you make up? Describe your relationship in five years. What do you see? What do you want to see?

10 Any additional information that you believe would assist us in understanding your situation? What family involvement would you like to see in the therapy? Are you currently suicidal at this time? Yes No If Yes, explain: