Diana Valdez, PhD, LPC
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- Thomasina Griffin
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1 Diana Valdez, PhD, LPC 1701 River Run, Suite 1107, Fort Worth, TX (817) ADULT BACKGROUND Name Date of Birth Street Address City, State, Zip Home/Cell Phone Work Phone Employer Occupation Emergency contact Name Phone address Who referred you to Dr. Valdez? Are you currently seeing another counselor? If so, whom? YOUR CURRENT CONCERNS (if not sure see list below): Describe briefly what led up to your calling a counselor and what you hope to get from counseling: 1
2 Indicate severity of up to 10 items (1-mild; 2-moderate; 3-severe) Circle the item that you see as the most significant issue) Adjustment to life changes (changing schools, parent s divorcing, moving, getting married or divorced, aging, etc.) Career Dissatisfaction or decisions Abuse (physical, emotional, sexual) Disturbing memories (past abuse, neglect or other traumatic experience) Drug or alcohol use (both legal and illegal drugs) Eating problem (purging, bingeing, overeating, hoarding, severely restricting diet) Feeling anxious (nervous, clingy, fearful, worried, panicky, obsessive-compulsive, lacking trust, etc.) Feeling angry or irritable Feeling guilty or shameful Feeling sadness or depression or suicidal urges related to grief Feeling sadness or depression or suicidal urges NOT related to grief Health concerns (physical complaints and/or medical problems) Illegal behaviors (repeated run-ins with the law, etc.) Learning/Academic difficulties Personal Growth (no specific problem) Significant other/spouse relationship Parent-Child relationship (discipline, adoption, single parent, etc.) Family or Step-family relationship Non-family relationship (roommates, friends, co-worker, boss, teacher, etc.) Religious or Spiritual concerns Sexual functioning concerns Sexual identity concern Sleep problem (nightmares, sleeping too much or too little, etc.) Speech problem (not talking, stuttering, etc.) Unusual experiences (loss of periods of time, sensing unreal things, etc.) Unusual behavior (bizarre actions, speech, compulsive behavior, tics, motor behavior problems, etc.) Other (explain ) *Please circle the most significant issue. When did you first become concerned about this/these issues? How have you attempted before now to deal with this issue? Describe what things you have already done to deal with your concerns: Describe the first, perhaps very small, signs that tell you things are improving: 2
3 PHYSCIAL HEALTH: Current weight: Weight 6 months ago: Ideal weight: Hours of sleep per night the past 2 weeks: Past 6 months: Kinds of exercise and number of times per week: Date of last physical and name of doctor/clinic: Medications you are now taking (list daily dosage and frequency): Do you have a thyroid condition? Yes / No Are you currently having suicidal thoughts or urges? Yes / No Have you ever attempted suicide? Yes / No PLAY: What do you do for fun? How many times per week? List when you took your last vacation, with whom, what you did: List when you ll take your next vacation, with whom, what you will do: RELIGION: What kind of religious background, if any, were you raised in? 3 What kind of religion, if any, do you practice now?
4 MILITARY: List military experience, if any: branch of service, highest rank, years, discharge status LEGAL: List dates and reasons for any arrests/criminal charges, including DWI: List dates and nature of convictions: List dates and places you did time in jail, prison, juvenile detention: Describe any current legal concerns, including criminal, civil, custody, bankruptcy, etc.: WORK: List educational degrees completed (year, institution, type of degree): List trade or professional licenses/certifications: What is your current job and how long have you been there? Describe briefly what you do. FRIENDS: List the first name of one or two of your closes friends, how you came to know them, how long you have been friends, when you last talked with them. ALCOHOL AND OTHER DRUGS List most recent use of each and how much: 4
5 Alcohol: Marijuana: Other drugs (specify): If you have been through chemical dependency treatment, please list when and where: Please list any 12-Step or support groups you attend per week: LIVING SITUATION: Describe where you live, how long you ve lived there, what the neighborhood is like: List name, relationship to you, and age of the other people you live with: List serious changes in health among members of your household or major ongoing health concerns: List names of persons who have joined or left your household in the past 2 years (include birth, death, and adoption): COMMITTED RELATIONSHIPS (if applicable): Where and when did you meet? Describe your parents and siblings reaction to your partner and your relationship to him/her: 5 Describe 2 strengths and 2 weaknesses in this relationship
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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
Alcorn & Allison. clinical associates **C O N F I D E N T I A L**
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Juniata College Health & Wellness Counseling Center INITIAL ASSESSMENT
Juniata College Health & Wellness Counseling Center INITIAL ASSESSMENT DATE Name Date of Birth Age Class Year Email Cell Hometown/State Emergency Contact Emergency Number Gender Identity Race/Ethnicity
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:
CONFIDENTIAL. Name Today s Date. Address: City: State: Zip: Phone number (cell): (home): (work): address: Emergency Contact (name): (number):
INTAKE FORM CONFIDENTIAL Name Today s Date Contact information: Date of birth Address: City: State: Zip: Phone number (cell): (home): (work): Email address: May I leave a voicemail on your cell or home
Application and History for Adult
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Homes of Hope Application
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MN Couple Therapy Center 1611 County Road B, Suite 204 Roseville, MN
MN Couple Therapy Center 1611 County Road B, Suite 204 Roseville, MN 55113 651.340.4597 FULL NAME DATE DOB Presenting Problem 1. What is/are the reason(s) you are seeking therapy today? 2. Did a specific
Transitional, Intergenerational Group Residence Application. Texas ID# Primary Language: Address: City, State, Zip Code: Phone-home ( ) Phone-work ( )
PERSONAL/FAMILY INFORMATION Name Date Date of Birth / / SS # Gender Texas ID# Primary Language: Marital Status: Single Divorced Common Law Living Together Married & living with Spouse not living with Spouse