BETHESDA WORKSHOPS: HEALING FOR MEN PARTICIPANT INFORMATION FORM
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1 BETHESDA WORKSHOPS: HEALING FOR MEN PARTICIPANT INFORMATION FORM Name Age Preferred first name Address City, State Zip Phone (Day) -_- Cell --_ address Occupation (indicate former occupation if retired) Marital Status Length of marriage years Spouse s name Prior marriages? Yes No How many? Former spouse's name # of years married Former spouse's name # of years married Reason for breakup(s) Children's names and ages FAMILY HISTORY Mother's name Still living? Yes No Year died Your age at her death Description of her during your childhood:
2 Healing for Men 2 Father's name Still living? Yes No Year died Your age at his death Description of him during your childhood: Siblings' names and current ages (in birth order - list yourself) Has anyone else in your family struggled with addiction? What kind? Is this person in recovery? How would you describe your childhood home? What was it like growing up in your family? What would you have changed if you could? What events stand out from your childhood?
3 Healing for Men 3 Were there other significant people in your childhood (either positively or negatively) other than your family of origin? Describe. Can you identify any abuse you experienced as a child? What kind (physical, sexual, verbal or emotional)? For how long? Who was the perpetrator(s)? Are there any other events, either in childhood or adulthood, that shaped who you are today?
4 Healing for Men 4 ADDICTION HISTORY Describe (non-graphically) your major acting out behaviors. (Example: pornography, affairs or serial relationships, promiscuity, prostitutes, strip clubs, compulsive masturbation, etc.) How old were you when you started acting out? Did you escalate to other activities? When? At what age? How much money have you spent acting out? _ What other consequences have you experienced? If married or in a significant relationship, when and how did your partner find out? Describe your relationship with your wife (or primary partner, if not married). How has your addiction impacted your relationship? (Or how did it in the past, if you're no longer married?) Have you struggled with any other addictive substances or behaviors? Include any history of gambling, work or food addiction. Describe. Are you sober now?
5 Healing for Men 5 MENTAL HEALTH HISTORY Are you in therapy now? yes no _. If so, for how long? _ If in the past, when and how long were you in counseling? Therapist's name and practice information: Name & credentials (M.A., Ph.D., CSAT, etc) Type of counselor (pastoral, layperson, licensed professional, psychologist, psychiatrist, etc.) Practice or organization name _ Address City, State Zip Phone NOTE: Your therapist MUST complete the Therapist Information Form if you're in current or recent counseling. If you re in couples counseling but not individual therapy, the couples therapist should complete the form. Give the Therapist Form (part of the paperwork link) to your clinician NOW. He/she will send it to Bethesda Workshops separately. It s due the same date as your other paperwork. What primary issues are you focusing on? Do you feel that your therapist is knowledgeable about working with sex addicts or partners? Have you ever had more than a passing thought of suicide? If so, when was the last time? Have you ever acted on suicidal thoughts? When? What did you do? (Describe attempt.) Are you suicidal now?
6 Healing for Men 6 Have you ever harmed yourself in any other way (for example, burning or cutting yourself)? What do you do? How often have/do you harm yourself? When was the last time? Have you ever been hospitalized or received in-patient treatment for your mental health, or attended any kind of intensive workshop? If so, describe what, when, and where. Are you currently taking antidepressants or anti-anxiety drugs? If so, what medication and how long have you been taking it? Is it effective? Have you taken such medication in the past? When? What? Is it effective? Do you have a mental or physical condition that workshop leaders should be aware of? (Examples: bipolar or panic disorder, hearing or sight difficulty, life-threatening food allergies or restrictions, use of a wheelchair or insulin pump, etc.) Note: With advance notice, we can accommodate requests for vegetarian and gluten-free meals. Other dietary needs are the participant s responsibility. We can t accommodate vegan meals or food that avoids your specific allergens. Contact the office to discuss your options for these special needs. I require: Vegetarian Gluten free Special needs (I ll bring my own food)
7 Healing for Men 7 RECOVERY HISTORY Do you consider yourself sexually / relationally sober now? If so, how long? How did you get sober? What's your definition of sobriety? Are you willing to do whatever it takes to achieve and maintain sexual sobriety? (Be honest.) How did you find out about Bethesda Workshop? (Please check) counselor (name_) former participant friend in recovery pastor (name) web search heard Bethesda Workshops leader speak or read something by leader other (how?_) What do you hope to gain by attending? What else do you want us to know? Signature Date NOTE: Please attach a recent photograph. You ll be asked to provide a photo ID at check-in.
8 Healing for Men 8 EMERGENCY MEDICAL INFORMATION Name: Birthdate EMERGENCY CONTACT: Bethesda Workshops will contact this person if you don t show up for your Healing Workshop without notifying us or if you leave before the workshop is over. Contact person in the event of a medical or other emergency (determined by BW s judgment): Name Phone (Day) -_- Relationship (Cell) - - Other name/numbers in case of emergency: _ INSURANCE: Who is your medical insurance carrier? NOTE: Workshop is NOT covered by insurance. This information is requested only for use in the event of a medical emergency. Company name _ Insured's name _ Policy or group # _ Medications you take regularly? (List name, frequency & dosage). Attach separate sheet if needed. Any critical medical information medical personnel should know about (diabetes, heart problems, life threatening allergies, recent surgeries or treatment, prosthesis, etc.)?
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COUPLE S INTAKE FORM CONFIDENTIAL Name Today s Date Contact information: Address: City: State: Zip: Phone number (cell): (home): (work): Email address: Date of Birth May I leave a voicemail on your cell
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Conscious Living Counseling & Education Center 3239 Oak Ridge Loop East, West Fargo ND (701)
Conscious Living Counseling & Education Center 3239 Oak Ridge Loop East, West Fargo ND 58078 (701) 478-7199 INTAKE FORM BIRTH DATE: / / Age: Email: YOUR NAME FIRST: MIDDLE INITIAL: LAST: YOUR ADDRESS COMPLETE
Adult Information Form
1 Client Name: Age: DOB: Today s Date Address: City: State: Zip: Home Phone: ( ) Ok to leave message? YES NO Work Phone: ( ) Ok to leave message? YES NO Current Employer (or school if a student): Gender:
311 North M.D. First Name. Race: Asian. White. Name. Phone: Coverage: made. Name Relationship
Robert Antonelle, M.D. White Plains Gastroenterology 311 North Street, Suite 403 White Plains, NY 10605 Patient Demographics Patient s Last Name First Name Middle Initial SSN Date of Birth Age Gender F
BARIATRIC PROGRAM PATIENT HEALTH HISTORY QUESTIONNAIRE (PLEASE PRINT CLEARLY)
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New Patient Intake. Boynton Health Mental Health Clinic. If you are new to the mental health clinic or have not been seen in over one year:
New Patient Intake Boynton Health Mental Health Clinic Welcome to the Boynton Health Mental Health Clinic The Mental Health Clinic is open to degree-seeking University of Minnesota Twin Cities campus students
Phone (h) (w) (c) Address. Referred by. Birthday Age Height Weight. Ethnicity Marital Status Children. Occupation Hours in regular work week
Client Intake Form Please fill out the following questions as best you can. If there is a particular question you don t understand or want to fill out, we can discuss them at our first meeting. Thank you.
Dr. Bruce Quinlan Christian Healing Counseling Ministry Intake Form and Informed Consent
Dr. Bruce Quinlan Christian Healing Counseling Ministry Intake Form and Informed Consent Today s Date: Name: Date of Birth Address: Gender: Male Female (Circle One) Age: How would you like me to contact
Intake Form. Presenting Problems and Concerns. When did it start and how does it affect you:
Intake Form Name: Date: Presenting Problems and Concerns Describe the problem that brought you here today: When did it start and how does it affect you: Estimate the severity of the above problem: Mild
Street City State Zip Code Social Security No: Telephone: Home: Marital Status: Q Single Work: Q Married Cell: Q Divorced
Richard Born, Ph.D. LLC Applied Psychological Health PATIENT INFORMATION Patient Name: Gender: Q M Q F Date of Birth: Address: Street City State Zip Code Billing Address if different from above: Street
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