Humanistic Psychological Services 831 Alamo Drive, Suite 5C, 6B, 6C Vacaville, CA Phone: (707) FAX: (707)

Transcription

1 Humanistic Psychological Services 831 Alamo Drive, Suite 5C, 6B, 6C Vacaville, CA Phone: (707) FAX: (707) Intake Paperwork for Adult Today s Date Referred By Please take time to fill out this form. This will aid greatly in providing appropriate therapeutic care for you. *General* Name Date of Birth Social Security Number Marital Status Address City: Zip: Phones (home) (cell) (work) Preferred Method of Contact Occupation Education Level *Emergency Contact Information* Name Relationship to Client Phone (Home) Alt Phone (Cell) *Responsible Party* Name Relationship to Client: Date of Birth Social Security Number Address: Phones (home) (cell) (work) *Financial Information* How do you intend to pay for treatment? (cash, check, charge, insurance) If planning to use health insurance: Name of insurance company Policy number Group number Employer Customer Service Phone # Subscriber Subscriber Date of Birth 1 P a g e

2 *Current Living Situation* Which of the following describe your current living situation? Please circle: Rent apartment Rent house Own house Foster care Condominium Shelter Homeless Group home Residential Treatment Your primary language spoken at home *Support System* List the household members living in your home at this time List important friends, family members or relatives living outside of the home *Areas of Concern* What issues/concerns causes you to seek treatment? Please describe. What are your specific goals with regard to your treatment? Do you have any particular concerns/fears with regard to treatment? 2 P a g e

3 *Psychological History* Have you ever received mental health treatment before? What was the focus of treatment? What did you find helpful/not helpful about treatment? Name of treating therapist Have you ever been subjected to one or more psychological tests? If so, by whom? Have you ever been hospitalized for mental or emotional problems? Why were you hospitalized? Name of Hospital *Current Medications* Please list current prescription medications you are taking Have you ever taken any medications for a mental or emotional condition? Have you ever attempted suicide? When? Describe the circumstances that led to that attempt. Are you currently having any suicidal thoughts? Please describe 3 P a g e

4 *Medical History* Have you ever been diagnosed with a serious illness? Please describe Do you have any medical conditions that may affect your mental health treatment? Please describe your overall health today. Date of last physical Name of physician Are you experiencing any medical/physical symptoms you attribute to a mental, emotional, or stress-related condition? Please describe. Have you ever been in a 12-step program? Yes No If Yes, please describe. If Yes, does it seem helpful? Yes No Do you smoke? How much? For how long? Do you drink alcohol? Yes No On average, how much alcohol do you consume in a week? Do you currently use illegal drugs? Please describe your use Have you ever used illegal drugs? Please describe. *Family of Origin History* Mother s name, age, living/deceased, patient s age at the time of mother s death, description of relationship with mother. Father s name, age, living/deceased, patient s age at the time of father s death, description of relationship with father. Names and ages of siblings. Please briefly describe your childhood experience Were you ever subjected to verbal, physical, emotional, sexual abuse? Please describe. Have you ever been a victim of a violent crime? Please describe 4 P a g e

5 *Other Information* Please describe your spiritual identity/orientation. Please describe your interests/hobbies Are you now or have you ever been involved in a lawsuit? Please describe. Do you currently have a parole officer? Yes Name No Do you have any restraining orders against you or someone else? Yes No If Yes, describe Please Check Off Any Areas You May Be Concerned About Check All That Apply Depression Strange Behaviors Lack Of Friends Crying A lot Paranoia Avoid Others Sexual Abuse Destroy Things Don t Pay Attention Obsessive Thoughts Learning Difficulties Stealing Anxiety Promiscuity Panic Attacks Physical Abuse Hopelessness Self-Injurious Behavior Obsessive Behaviors Suicidal Thought/Plans Vandalism Hot Temper Odd Beliefs Fire Setting Gambling Too Much Chemical Use Violence Nightmares Hyperactivity Worry Excessively Perfectionist Gender Confusion Mood Changes Weight Loss Fighting Your Strengths - Check All That Apply Stay Active Easy Going Have A Hobby Employed Intelligent Artistic Attend School Work Caring Athletic Regularly Copes Well With Issues Sharing With Others Liked By Others Independent Maintain Friends Structure Time Well Positive Outlook Hard Working Responsible Spiritual Playful Good Health Humorous Good Looking Honest Helpful A Leader Positive World *Others:* Any other information that would be helpful to know in helping you? Thank you for taking the time to fill out this intake form. Printed Name Signature Date: 5 P a g e