CLIENT QUESTIONNAIRE. Preferred Name: Address: (Street) (City/State) (Zip Code) Home Phone: Cell Phone: Relationship: Cell Phone:
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1 CLIENT QUESTIONNAIRE Full Legal Name: DOB: / / Preferred Name: Address: (Street) (City/State) (Zip Code) Home Phone: Cell Phone: Can we leave voice messages for you at these numbers? Yes Text Messages? Yes EMERGENCY CONTACT INFORMATION: Name: Home Phone: Relationship: Cell Phone: Name: Home Phone: Relationship: Cell Phone: Hospital Preference: CULTURAL PREFERENCES: Ethnic Identification: African American Caucasian Latino Hispanic Asian Native American Other, Please Explain: Sexual Identification: Heterosexual (Straight) Gay/Lesbian Bisexual Other, Please Explain: Religious/Spirituality Identification: Catholic Protestant n-denominational Christian Jewish Hindu Muslim Buddhist Agnostic Athiest Jehovah s Witness Other: Please Explain: Are you satisfied with your spirituality? Yes Please Explain: Gender Identity and Expression:
2 Marital Status: Single Partnered/Cohabitating Married Divorced Separated Widowed Other, Please Explain: Employment Status: Employed FT Employed PT Student FT Student PT Self-Empl. Unemployed Other, Please Explain: Please tell us a little bit about what is bringing you in today: PSYCHOLOGICAL SYMPTOMS AND HISTORY: Please check any of the following that are currently bothering you: Feeling Tense Past or Present Trauma Feeling Lonely Low Motivation/Energy Level Hopelessness Suicidal Thoughts Mood Swings Racing Thoughts Worrying about what others think of me Negative thoughts about myself Eating Disorder Sleeping Too Much Problems Falling or Staying Asleep Grief or Loss Difficulty Controlling Anger Substance Use Gambling Seeing or hearing things that other people don t Couple s/relationship Problems Worrying too much/feeling afraid Avoiding things I am afraid of Isolating/Withdrawing Feeling Numb Crying Easily Self-Injury Difficulty Making Decisions Feeling High (Without Substance Use) Seeking reassurance from others My Weight/Appearance Chronic Pain t Sleeping Enough Nightmares Irritability Being violent or wanting to be violent Sex Addiction Impulsivity Difficulty Controlling Thoughts Problems with my Kids
3 HAVE YOU EVER EXPERIENCED THE FOLLOWING: Physical Abuse Sexual Abuse Emotional/Verbal Abuse Neglect Have you ever abused another person? Yes Have you ever experienced a life-threatening event (i.e. combat, natural disaster, accident, serious injury, watched another person die, violent crime, etc.)? Yes PAST TREATMENT EXPERIENCES: Have you ever participated in mental health treatment in the past? Yes If so, please describe: Has anyone in your immediate family ever struggled with mental health conditions (i.e. anxiety, depression, suicide, substance use, etc.): Yes If so, please describe: HEALTH INFORMATION: Who is your primary care physician? Date of your last primary care visit: / / Would you like to sign a release of information to involve them in your care with us? Yes If you are experiencing any current medical conditions that you believe could impact your mental health treatment, please describe them here:
4 Please list all of the medications (prescribed or over-the-counter) that you are currently taking: Medication: Dosage: Prescribed By: Please list any psychiatric medications that you have been prescribed in the past: Who is your current psychiatrist? Date of your last psychiatry visit: / / Would you like to sign a release of information to involve them in your care with us? Yes If you do not currently have a psychiatrist, are you interested in a referral for one? Yes
5 SUBSTANCE USE SCREENING: Please fill out the following chart regarding your substance use history (only complete boxes 5-11 for substances that you are currently using): Type of Substance: Current Use? Used in the Past? Age of First Use? How often and how much do you use (example: 4 beers 3 times/week or $20 worth 2 times/week)? Withdrawal symptoms when you stop using? Have you ever tried to stop or cut down? Have you ever taken more than planned? Has it caused problems (at work, financial, in relationships, health, etc)? Tolerance (have to use more to get the same effect)? Have you continued to use despite it making your problems worse? Alcohol Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Cannabis/Marijuana Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Opiates Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Cocaine Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Benzodiazepines Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Hallucinogens Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Inhalants Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Caffeine Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Nico tine Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N FAMILY INFORMATION: Please tell us about the other people living in your home: Name: Relationship to You: Age: Comments:
6 Do you have additional children who are not currently living in your home? Yes If so, please list them here: Name: Age: Living With: Comments: Please list additional family members below (i.e. parents, siblings, step-family, adoptive family, ex-partners of importance, etc.): Name: Relationship to You: Age (or age at death): Comments (please comment if deceased): EDUCATIONAL/OCCUPATIONAL HISTORY: What is the highest level of education that you completed? Middle School GED High School Diploma Some College, Degree Associate s Degree Bachelor s Degree Master s Degree Doctorate Do you have any difficulties with learning? Yes Difficulties with reading/writing? Yes What do you identify as your strengths that will help you achieve your goals?
7 Please list the past five jobs that you have had: Place of Employment: Position: Length of Time Employed: Comments: Did you ever serve in the U.S. military? Yes If so, what branch? What years did you serve? Did you experience combat? Yes LEGAL HISTORY: What is your current legal status: Clear Awaiting Trial Probation Parole Other, Please Explain: If you are currently experiencing legal problems, would you like to sign a release of information for your legal providers? Yes Please list any past legal charges and/or incarcerations: Dates: Charges: Results (probation, incarceration. etc.):
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Office Use Only Client # Ins. Dx: Need Monthly Statement? Yes No EAP Yes No Individual Family Today s Date: GENERAL INFORMATION Please print Client Name: Last First: MI: Mailing Address: City: State: Zip:
Name: Date: Who referred you? Current Psychiatrist: Clinical Information:
LIFE HISTORY QUESTIONNAIRE Adult The purpose of this questionnaire is to obtain an understanding of your life experience and background. Then we can begin to develop a comprehensive treatment program suited
Joan B. Jablow, APMHNP 45 Byram Lake Road Mt. Kisco, New York (914)
Joan B. Jablow, APMHNP 45 Byram Lake Road Mt. Kisco, New York 10549 jablownp@optimum.net (914) 241-1246 Personal Adult (18+) Client s name: Date: Gender: F M Date of birth: Age: Address: City: State: Zip:
Last Name First Middle Date of Birth Age. Residence Address City State Zip Code
The following necessary information will help make your first session most productive. Please PRINT and fill out this form COMPLETELY. DEMOGRAPHICS Date: Last Name First Middle Date of Birth Age Residence
A New Tomorrow Behavioral Health Services
A New Tomorrow Behavioral Health Services Tara L. Corbett MS, LPC Jenais Y. Means MA, LPC-I Linda L. Leech PhD, LPC, LPC-S Natasha Moseng MS, LPC-I 2635-A Hardee Cove, Sumter, S.C. 29150 Phone: (803) 883-4981
Northside Mental Health Center Intake Questionnaire
Name: _ Date of Birth: Age: SS# Address: City & State: Zip Code: GOALS How may we help you today? What type of help would you like? Circle all that apply Counseling Medication See a doctor What would you
Client Name: Date of Birth: Address: City: Zip code: Hm #: ( ) -. Cell#: ( ) -. Wrk#: ( ) -. Otr#: ( ) -.
New Client Intake Date: Client Name: Date of Birth: Address: City: Zip code: Hm #: ( ) -. Cell#: ( ) -. Wrk#: ( ) -. Otr#: ( ) -. Employer Email: Emergency Contact Name Relationship Phone number TREATMENT
New Client Questionnaire: (rev. 08/2016)
New Client Questionnaire: (rev. 08/2016) Client Name: Date of Birth: / / Date of First Session: / / What events or concerns brought you to my office? What goals would you like to accomplish? Are there
TOOL 1: QUESTIONS BY ASAM DIMENSIONS
TOOL 1: QUESTIONS BY ASAM DIMENSIONS The following tool highlights specific questions that should be asked of the patient for each ASAM dimension. Name Date of Birth Date of Interview Address Referred
Medications. New Patient Registration. Billing and Insurance. Phone Calls. Prescription Refills. Lab Results and Test Results
Dear New Patient: We would like to welcome you to our practice. Our goal is to make your experience with us as pleasant as possible. In order to help us meet this goal we have listed some helpful hints
ADULT INITIAL EVALUATION: Patient Form
ADULT INITIAL EVALUATION: Patient Form Date: Patient: DOB: Referred by: Name of Person completing this form if not patient: Briefly describe the events that led to this appointment. Have there been any
CHILD/ADOLESCENT SELF-REPORT FORM (To be completed before initial intake)
CHILD/ADOLESCENT SELF-REPORT FORM (To be completed before initial intake), LLC 2383 University Ave West, Suite 200 Saint Paul MN 55114 Phone: 651-644-4100 Fax: 651-644-4100 Date: Form Completed By: Relationship