Teresa Donato Licensed Clinical Professional Counselor 512 North 29 th, Suite INTAKE FORM/DIAGNOSTIC ASSESSMENT
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1 Teresa Donato Licensed Clinical Professional Counselor 512 North 29 th, Suite INTAKE FORM/DIAGNOSTIC ASSESSMENT Name: Address: Date: Telephone Numbers: Best times to call: Emergency Contact Information: Date of Birth: Age Birthplace: Marital status: Previous marriages: Children: Step-Children: CURRENT LIVING SITUATION (Own home? How do you support yourself? EDUCATIONAL HISTORY College? HS? What was your experience like in school VOCATIONAL HISTORY Do you work? Favorite job? Like job? Job goals? Career goals? Military History? Experiencing legal situation, unemployment, financial problems, parole, probation? Intake page 1
2 PRESENTING CONCERN/REASON FOR COUNSELING Describe concern: Presenting concerns intensity: How do you rate the intensity of the concern that brought you in: 1 Not intense 2 3 Moderately intense 4 5 Extremely Intense Problem duration: Approximately how long have you had the current problem? Coping attempts: How have you dealt w/this problem on your own? History of Mental Health Services and Diagnoses: What is your most specific goal in counseling? Major goals in life: Does your current mental health prevent you from obtaining these goals? Have you had suicidal thoughts recently? Have you ever had suicidal thoughts? Have you ever intentionally inflicted harm upon yourself? Intake page 2
3 FAMILY HISTORY Place of Birth: Birth Order: # Siblings: Name of Sibling: Gender/Age Closeness Family information - (Mother/Father age, location, closeness, disciplinary measures, deaths in family, violence in home, trauma, frequent or traumatic location, serious illness in family, psychiatric disorders in family, suicide in family, physical or sexual abuse): Who in your family do you feel closest to, distant from, most conflict with, most supportive? Describe a favorite memory from your childhood? What do you consider is some of your best traits and strengths? Is there anything that you do not like about yourself? Do you consider yourself shy or inferior? If so, has this affected your lifestyle? Problems sleeping/nightmares? Hobbies/Music/recreation: Diet/caffeine/exercise: Intake page 3
4 MEDICAL HISTORY: Current medical complaints/problems: History of: Y/N Describe Serious Injury Serious Illness Head Injuries Seizures Allergies Physical Limitations Current Medications: Name Dosage Duration Taking Past psychotropic medications used: Name Dosage Duration Taking How do you feel about your present state of health? Family physician (name and location): Intake page 4
5 ALCOHOL OR ILLEGAL DRUG USE: Do you currently use alcohol or illegal drugs? Substance Amount How often Have you ever had a CD evaluation? Have you ever been told you are an alcoholic Do you feel that your alcohol/drug use is abnormal? Have you ever had a blackout? Approximately how many times have you been drunk or high in the last year Y/N History of chemical dependency treatment? How has chemical dependency affected your life/family history? Codependency/gambling/tobacco: Intake page 5
6 SYMPTOMS Y/N Describe (duration, frequency, etc.) 1. Mood a. Depressed mood b. Elevated mood c. Cyclic 2. Sleep a. Insomnia b. Hypersomnia c. Decreased Need 3. Appetite problems 4. Weight change 5. Interest in Activities 6. Energy 7. Concentration Difficulty 8. Hopeless/Helpless feelings 9. Worthless/guilt feelings 10. Crying 11. Suicidal Ideation 12. Homicidal Ideation 13. Sexual Interest/Dysfunction 14. Hallucinations 15. Delusions 16. Thought Control 17. Alcohol Abuse/Dependency 18. Chemical Use/Dependency 19. Panic Attacks 20. Phobias 21. Anxiety (generalized) 22. Traumatic Events 23. Flashbacks 24. Nightmares 25. Avoidance 26. Irrational thoughts 27. Obsessions/compulsions 28. Memory 29. Physical condition 30. Anorexia 31. Bulimia 32. Aggression/Anger 33. Hyperactive 34. Impulsive 35. Tics 36. Socially Withdrawn 37. Poor Social Skills 38. Indiscriminate boundaries 39. Responsibility 40. Confusion or foggy thinking 41. Decision making 42. Phobias/Fears Intake page 6
7 Additional Information? Intake page 7
ADULT INTAKE FORM. Name
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Please check all the behaviors and symptoms that you consider problematic:
Name Date Address Phone # Date of birth Email address Social Security Describe the issue that brought you here today: Please check all the behaviors and symptoms that you consider problematic: Distractibility
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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
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COUNSELING INTAKE FORM Name Age Date Full Address Home Phone Work E-mail Work History Occupation How long? If presently unemployed, describe the situation Hobbies/Avocations Any past/present military service?
APPLICATION FOR ADMISSION
The Women s Home, Inc. P.O. Box 7412, Arlington, VA 22207-9998 703/237-2822; Fax: 703/237-1167 e-mail: womenshm@aol.com; Web site: www.thewomenshome.com APPLICATION FOR ADMISSION Name: SSN: Birth Date:
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Intake Form. Presenting Problems and Concerns. When did it start and how does it affect you:
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Address: Spouse/Partner Name: Phone: Address:
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Patient Questionnaire. Name: Date: A. What are the main concerns or problems that brought you here today?
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Health and Social Information 1. How is your physical health at present? (Please circle) Poor Unsatisfactory Satisfactory Good Very good
Client Health History and Background Please provide the following information for my records. Continue on the backside of this form if you need additional space. General Information Name: Date: Birth Date:
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-S, BCN 5604 Wesley Street, Suite 103; Greenville, TX 75402 Phone: 903-274-4140; COUPLE S INTAKE PAPERWORK Separate forms to be completed by each party Client s name: Date: Gender: F M Date of birth: Age:
BACKGROUND HISTORY QUESTIONNAIRE
BACKGROUND HISTORY QUESTIONNAIRE Name: Sex M F Address: Home Number: Work Number: Cell Number: Email: SSN: Name and Address of Employer: Date of Birth: Age: Ethnicity: Referred By: Referral Question or
ADULT INTAKE QUESTIONNAIRE. Ok to leave message? Yes No. Present psychological difficulties please check any that apply to you at this time.
ADULT INTAKE QUESTIONNAIRE Name: Today s Date: Age: Date of Birth: Address: Home phone: Work phone: Cell phone: Ok to leave message? Yes No Ok to leave message? Yes No Ok to leave message? Yes No Email:
Initial Evaluation Template
Demographic Information (Please complete all questions on this form) Member Name: Date: Name: Address: Phone (Home): Phone (Work): Date of Birth: Social Security #: Guardianship (for children and adults
PSYCHIATRIC CLINIC, LLC 123 Main Street Anywhere, US (O) (F) Nesmith, Kelly.
Page 1 of 7 PSYCHIATRIC CLINIC, LLC 123 Main Street Anywhere, US 12345-6789 555-678-9100 (O) 555-678-9111 (F) DATE ADMITTED: 4/24/2017 DATE DISCHARGED: This discharge summary consists of 1. Initial Assessment
ADULT PATIENT AND FAMILY INFORMATION FORM
Psychiatry and Behavioral Health at ADULT PATIENT AND FAMILY INFORMATION FORM IDENTIFYING INFORMATION Date Completed: Name: Cell Phone: Date of Birth: Gender: Work Phone: Home Phone: Employer: Marital