Kiana Gaston, B.A., Practicum Student Supervised by Debbie Edmunds, MA, LPC-S
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1 Kiana Gaston, B.A., Practicum Student Supervised by Debbie Edmunds, MA, LPC-S New Patient Questionnaire/Psychosocial History (To be completed by the Patient) Please complete this form to the extent that you feel comfortable. If any questions are particularly difficult, painful, or not applicable, please feel free to leave them blank and/or discuss them with me during your session. If you need more space for any answers, please use margins or back of sheet. Name: Date: Gender: F M Date of Birth: Age: Referred By: (e.g., Name of physician, website, friend, yellow pages, etc.) Primary reason(s) for seeking services: Family Information Living? Lives with you? Relationship Name Age Yes No Yes No Mother Father Spouse/Partner Children Significant others (e.g., siblings, grandparents, etc.) Please specify relationship. Living? Lives with you? Relationship Name Age Yes No Yes No
2 Current Marital Status: (please circle all that apply) Single Married Living together Committed relationship Divorced Widowed Engaged Separated Length of current marriage/relationship: Number of marriages/serious relationships: Assessment of current relationship (if applicable): I feel safe in my current living situation: Yes No (please explain) I feel safe in my current romantic relationship: Yes No (please explain) Growing up, I was raised by/lived with: My childhood was: I usually get along with my parents: Yes No because: I usually get along with my siblings: Yes No because: Development Are there any special, unusual, or traumatic circumstances that affected your development?
3 Type of discipline used in my home when growing up: Has there been a history of abuse in your past? Yes No If yes, which type(s): Emotional/verbal abuse Physical Sexual Neglect/Abandonment Comments: Social Relationships I usually get along with other adults: Yes No because: I usually get along with children: Yes No because: I have friends: No Yes # Males #Females Sexual orientation: Comments: Sexual problems or dysfunction: Yes If yes, describe: No Cultural/Ethnic With which cultural, racial, or ethnic groups do you identify? Are you experiencing any concerns related to cultural, racial, or ethnic issues? No Yes If yes, please describe: Other pertinent cultural/racial/ethnic information:
4 Religious/Spiritual Affiliation: Would you like your spiritual/religious beliefs incorporated into therapy? Yes No If yes, please describe: Legal I have been involved with the legal system: No Yes Describe: Education/Employment Highest level of education completed (including school name and diploma/degree): Currently enrolled as a student? No Yes Current employer: N/A Job title/occupation: N/A Career Concerns? Military experience (i.e., branch, rank, type of discharge, combat experience, etc.): N/A Medical/Physical Health I have the following medical problems: List all current medical issues and past accidents/surgeries/medical issues that may still affect you presently. I take the following prescription or over the counter medications including vitamins/supplements/herbs:
5 Name of medicine Reason Use additional space at bottom/back of this page if needed. Please describe any recent changes in sleep, eating, behavior, weight, disposition, or energy level: List any concerns you may have about your sleep and/or eating habits: Chemical Use History I have used the following types of alcohol/illegal substances: put a * by your drug of choice Name of drug Age of first use Amount/Frequency Date of last use Are you or someone you love concerned about your use of alcohol or drugs? Yes No Have you ever sought help (inpatient treatment or 12 step program) for substance abuse or addiction? Yes No If yes, please describe: Please list any family history of drug or alcohol abuse: Counseling/Prior Treatment History I have cut, burned, scratched, or hurt myself before: No Yes If yes, please explain:
6 I have attempted suicide before: No Yes If yes, please explain: Are you currently suicidal? No If yes, please explain: Yes I have thought about killing someone else: No Yes because: I have had previous treatment (e.g., inpatient, private therapist, residential treatment): No Yes because: If you have previously seen a therapist, what did you like or dislike about that experience I am willing to receive therapy: No because: Yes because: What are your expectations or goals for therapy? Please list any other information that might be helpful in understanding you or assist in your therapy: Patient or Legal Guardian Name: Patient or Legal Guardian Signature:
Nathan Driskell, MA, LPC, NCC
Nathan Driskell, MA, LPC, NCC https://nathandriskell.com New Client Questionnaire/Psychosocial History (To be completed by the client) Please complete this form to the extent that you feel comfortable.
ADULT PATIENT HISTORY FORM. Name: Address: City: State: Zip: Occupation (if applicable): Religious Affiliation (if applicable):
ADULT PATIENT HISTORY FORM DEMOGRAPHIC INFORMATION: Name: Address: City: State: Zip: Age: Date of Birth: Gender: Male Female Transgender Marital Status: Never Married Domestic Partners Married Separated
Client Information Form
Client Information Form General Information Date: Name: Date of Birth: Age: Current Address: Home Phone: Cell Phone: Best number and time to reach you directly: Can I leave a message at either or both
Choice Counseling Associates
Amy Vitacolonna, MS, LMHCA, RT/CT 719 Sleater-Kinney Rd SE, Suite 212 Lacey, WA 98503 (360) 349-8775 (office) (360) 584-9048 (fax) ChoiceCounselingAssociates@gmail.com ChoiceCounselingAssociates.com Choice
COUNSELING INTAKE FORM
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?
Demographic Information Form
Demographic Information Form PATIENT INFORMATION Male Female Other / / (Patient Legal Last Name) (Patient Legal First Name) (MI) (DOB) Mailing: SSN#: - - Home Cell Relationship Status (circle one): Single
Demographic Information Form
PATIENT INFORMATION Demographic Information Form / / Mailing: Male Female SSN#: - - Home Cell Relationship Status (circle one): Single / Married / Divorced / Widowed / Other: ( ) - ( ) - (Preferred Phone
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:
WOODBRIDGE THERAPY GROUP
Personal History Adult Client s name: Date: Gender: F M Date of birth: Age: Form completed by (if someone other than client): If you need any more space for any of the questions, please use the back of
Heron Ridge Associates, PLC PARTNER RELATIONAL PERSONAL HISTORY INFORMATION. Client s Last Name First Name M.I. Street Address Date of Birth Age
Case #: Readmit? Yes No Heron Ridge Associates, PLC PARTNER RELATIONAL PERSONAL HISTORY INFORMATION PLEASE PRINT CLEARLY Today s Date: Client s Last Name First Name M.I. Street Address Date of Birth Age
Sofia P. Simotas, Ph.D., PLLC 2524 Nottingham St. Houston, Texas 77005
Sofia P. Simotas, Ph.D., PLLC 2524 Nottingham St. Houston, Texas 77005 INTAKE FORM Name: Date: Gender: Female Male Date of birth: Address: Home phone: Cell: Okay to leave a message? Yes No Email: Emergency
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
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:
Adult Information Form Page 1
Adult Information Form Page 1 Client Name: Age: DOB: 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
Richmond Counseling Center
Personal History Adult Client s name: Date: Gender: F M Date of birth: Age: Form completed by (if someone other than client): Address: City: State: Zip: Phone (home): (work): ext: If you need any more
COLUMBUS PSYCHOLOGICAL ASSOCIATES, L.L.P.
COLUMBUS PSYCHOLOGICAL ASSOCIATES, L.L.P. 2325 BROOKSTONE CENTRE PARKWAY / COLUMBUS, GA 31904 PHONE: (706) 653-6841 FAX: (706) 653-7843 Adult Outpatient Psychosocial History Psychosocial Self-Assessment
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
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
Azimuth Counseling and Therapeutic Services P.O. Box 8268 Essex Junction, VT Personal History Adult (18+)
Azimuth Counseling and Therapeutic Services P.O. Box 8268 Essex Junction, VT 05451-8268 Personal History Adult (18+) Client s name: Date: Gender: F M Date of birth: Age: Form completed by (if someone other
MINDFUL WELLNESS CENTER, PLLC
PATIENT HISTORY NAME DATE PLEASE TAKE YOUR TIME AND COMPLETE THE ENTIRE FORM. You may use the back if needed for more explanation. Identifying Information: Date of Birth: Age: Sex: Place of Birth: Religion:
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
ADULT INTAKE FORM. Name
Welcome to Solace Counseling Associates. Please note that the information is important for your care. Please fill out forms as completely as possible and have them ready before your first counseling session.
*Please complete this form and bring to your first appointment. This information is fundamental to the assessment and treatment process.
*Please complete this form and bring to your first appointment. This information is fundamental to the assessment and treatment process. PATIENT CONTACT INFORMATION Name Age Date of birth Phone ( ) Mailing
Rum River Counseling, Inc.
Page 1 of 8 Rum River Counseling, Inc. PERSONAL HISTORY - ADULT Client s name: Date: / / Gender: F M Date of birth: / / Age: Form completed by (if someone other than client): Address: City: State: Zip:
ITGW 5914 Hubbard Drive Rockville, Maryland (301)
ITGW 5914 Hubbard Drive Rockville, Maryland 20852 (301) 468-4849 www.greaterwashingtontherapy.com ADULT INTAKE FORM Client s name:_ Date Gender: F M Date of birth: _ Age: Form completed by (if someone
2015 Peoples Counseling and Consulting. Improved relationships with oneself & others 4509 South 6th Street, Suite 307 Klamath Falls, Oregon 97603
Improved relationships with oneself & others Peoples Counseling & Consulting 4509 South 6th Street, Suite 307 Klamath Falls, Oregon 97603 T 541.274.9551 F 541.205.3871 E jaypeoples @ counselingpeople.com
*IN10 BIOPSYCHOSOCIAL ASSESSMENT*
BIOPSYCHOSOCIAL ASSESSMENT 224-008B page 1 of 5 / 06-14 Please complete this questionnaire and give it to your counselor on your first visit. This information will help your clinician gain an understanding
Full Circle Psychotherapy: Ayla Marie Carter, MA, LMHC
Full Circle Psychotherapy: Ayla Marie Carter, MA, LMHC aylacarter@fullcirclepsychotherapy.org www.fullcirclepsychotherapy.org (253) 686-4681 Name (First, Middle, last): Birthdate: Age: Gender: Sexual Orientation:
New Client Information. address: Date of Birth:
Milwaukee Area Psychological Services, S.C. (MAPS) 401 E. Kilbourn Avenue, Suite 402 Milwaukee, WI 52302 414-269-8660 (phone) 414-269-8656 (fax) New Client Information Your responses to the following questions
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:
Life s Journey Counseling and Community Services LaToya Martin-Jackson, MA, LPC, NCC Lic.# 66427
Life s Journey Counseling and Community Services LaToya Martin-Jackson, MA, LPC, NCC Lic.# 66427 Personal History Adult (18+) Client s name: Date: Gender: F M Date of birth: Age: Form completed by (if
Azimuth Counseling and Therapeutic Services 8 Essex Way, Suite 101 Essex, VT Personal History Adult (18+)
Azimuth Counseling and Therapeutic Services 8 Essex Way, Suite 101 Essex, VT 05452 Personal History Adult (18+) UPDATED 7/28/16 Client s name: Date: / / Gender: F M Date of birth: / / Age: Location of
PERSONAL HISTORY - ADULT
41800 Hayes Rd, Suite 305 39293 Plymouth Rd, Suite 109A Clinton Township, MI 48038 Livonia, MI 48150 bhconsultantsllc@gmail.com Phone: 734-772-8862 www.bhconultantsllc.com Fax: 734-943-6321 PERSONAL HISTORY
ADULT INFORMATION FORM
ADULT INFORMATION FORM Instructions: To assist in helping you, please fill out this form as fully and openly as possible. All private information is held in strictest confidence within legal limits. 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
ADULT INFORMATION SHEET
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Diana Valdez, PhD, LPC
Diana Valdez, PhD, LPC 1701 River Run, Suite 1107, Fort Worth, TX 76107 (817) 332-1425 dianavaldezphd@gmail.com ADULT BACKGROUND Name Date of Birth Street Address City, State, Zip Home/Cell Phone Work
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
PERSONAL HISTORY QUESTIONNAIRE
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Adult Intake Form. Name: Date: Describe the problem that brought you here today: Briefly share relevant history behind this problem:
Adult Intake Form Date: Describe the problem that brought you here today: Briefly share relevant history behind this problem: Check any of the following symptoms that you are experiencing: Distractibility
Evergreen Behavioral Health Psychiatric Intake Form. Name: Date: Date of Birth:!
Name: Date: Date of Birth: NOTE: Please also fill out the standard Evergreen Behavioral Health Adult Client Information form to accompany this one if you have not yet done so. Please also bring in recent
Address: Spouse/Partner Name: Phone: Address:
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Gishela Satarino, MA, LPC-S 6750 Hillcrest Plaza Drive, #203 Dallas, TX 75230 214-280-3664 History Form for Counseling Services Client s Name: Age: Today s Date: / / Client s Sex: Client s Birthplace:
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:
Henrike B. Kroemer, Ph.D. ADULT HISTORY FORM
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Preferred Name (s): Local Address: City: State: Zip: Permanent Address: City: State: Zip: Years of Education: Occupation: Gender: M F
Today Date: Client Name(s) : Psychological Consultants Northgate Center 1210 ½ -7 th Street NW, Suite 216 Rochester, MN 55901 www.psychologicalconsultants1.com Office: (507) 252-9292 Fax: (507) 252-9203
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Humanistic Psychological Services 831 Alamo Drive, Suite 5C, 6B, 6C Vacaville, CA Phone: (707) FAX: (707)
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Client Intake Form Thank you for taking the time to openly and honestly answer the questions below. Your genuine responses are appreciated, as all information provided will assist your therapist to better
Name: Date: Who referred you? Current Psychiatrist: Clinical Information:
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Name: Date of Birth: Address. Why I came for this visit: Who lives with you? Occupation:
BARIATRIC ADULT PSYCHOLOGICAL HISTORY Name: Date of Birth: Address Why I came for this visit: Who lives with you? Occupation: [ ] Live alone [ ] Spouse [ ] Partner Education: [ ] High School [ ] Some College
Name: Birthdate: Gender: Address: Phone: (Home) (Work) (Cell) Highest Education Attended: Occupation: Place of Employment:
CLIENT CLIENT INTAKE FORM Client Information Name: Birthdate: Gender: Address: Is it safe to send correspondence to this address, if needed? Yes No Phone: (Home) (Work) (Cell) Is it safe to contact/leave
CLIENT INTAKE FORM. Please describe your main reason(s) for seeking services at this time?
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New Patient Questionnaire
New Patient Questionnaire Date of appointment (MM/DD/YYY): Name (Last, First, MI): Previous Names: DOB (MM/DD/YYY): Phone: Cell: Email: May we email you with sensitive information, such as test results?
New Client Questionnaire: (rev. 08/2016)
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YMCA of Reading & Berks County Housing Application
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Patient Intake Questionnaire Note: This is a sample intake questionnaire which includes a wide variety of potential questions that can be asked of new clients during the intake process. Providers are encouraged
CONFIDENTIAL. Name Today s Date. Address: City: State: Zip: Phone number (cell): (home): (work): address: Emergency Contact (name): (number):
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BACKGROUND HISTORY QUESTIONNAIRE
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Hope in Healing Counseling and Wellness, LLC Stacy Nunne, MA, LMFT, SEP, RN 600 West 78th Street, Suites 10A-C Mailing Address: PO Box 892 Chanhassen, MN 55317 Chanhassen, MN 55317 Phone: 952-215-5208
PATIENT IDENTIFICATION: Name: First Appointment Date: Birth Date: Address: City State Zip Home Phone #: Work #: Cell #: REFERRAL SOURCE: Referred By:
Andrew E. Leifer, M.D., P.C. 1202 Bergen Parkway, Suite 211 Evergreen, Colorado 80439 General Adult Psychiatry Outpatient and Hospital Care Medical Consultation-Liaison Service Telephone (303) 674-6074
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Journey to Truth Counseling
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Name: Gender: male female Age: Date of birth: / / Preferred phone: cell home work other. Alternate phone: cell home work other.
Casey Alexander Paleos, MD NEW CLIENT INTAKE FORM 775 Park Avenue, Suite 200-2 Huntington, NY 11743 tel 631-629-5887 Date: / / BASIC INFORMATION Name: Gender: male female Age: Date of birth: / / Preferred
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Lyris Bacchus Steuber, MS, LMFT MT Harley Lester Lane Apopka, FL Ph: , Fax:
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MINOR CLIENT HISTORY
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Crawford consulting and mental health services, inc ADULT PSYCHOSOCIAL ASSESSMENT
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Date of Assessment ADULT PSYCHOSOCIAL HISTORY/INITIAL THERAPY INTAKE FORM Identifying Information: Name: Address: Age: D.O.B: Phone Number: Race: Gender: Religious Affiliation(optional): Current Household
ALVIN C. BURSTEIN, MD PATIENT CLIENT INFORMATION
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Susan Weltner-Brunton, Ph.D. & Associates, Inc. 921 Chatham Lane, Suite 112 Columbus, Ohio Phone Fax
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Name Last First Middle Date. Completed by: If not client, relationship to client. Reason for Seeking Counseling:
CLIENT HISTORY (PSYCHOLOGICAL, SOCIAL, PHYSICAL and SPIRITUAL) Name Last First Middle Date Completed by: If not client, relationship to client Reason for Seeking Counseling: Personal Information Sex: [
Physical Issues: Emotional Issues: Legal Issues:
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Patient Questionnaire. Name: Date: A. What are the main concerns or problems that brought you here today?
Patient Questionnaire Name: Date: D.O.B.: Age: Referred By: Presenting Problem A. What are the main concerns or problems that brought you here today? B. Problem Checklist: please circle all that apply:
Client s Name: Street City State Zip. Home Phone Work Phone Cell Phone. Student: Full-time Part-time Grade School. Current or past Education:
Office of: Sarah Horvath, LCSW Self-Report Form Page 1 Client s Name: Person completing report: Relation to Client: Street City State Zip Home Phone Work Phone Cell Phone Email: Date of Birth: Age: Gender:
Name Last First Middle Date. Completed by: If not client, relationship to client: Reason for Seeking Counseling:
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Amanda G. Johnson, LPC
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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:
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
BIOPSYCHOSOCIAL SCREENING ADULT
BIOPSYCHOSOCIAL SCREENING ADULT CHART NUMBER: DOB: 1. IDENTIFYING INFORMATION Client Name: Availability: Family Member Name: Availability: Family Member Phone Numbers: Telephone (Day): Telephone (Eve):
ADULT HISTORY QUESTIONNAIRE
ADULT HISTORY QUESTIONNAIRE Date: Full Name: Date of Birth: If applicable, please complete the following: Partner s Name: Partner s Age: Partner s Occupation: IF YOU HAVE CHILDREN PLEASE LIST THEIR NAMES
CLIENT HISTORY CLIENT LEGAL NAME: CLIENT PREFERRED NAME:
CLIENT HISTORY CLIENT LEGAL NAME: DATE: CLIENT PREFERRED NAME: FAMILY & SOCIAL BACKGROUND Please list and describe your current family members (immediate, extended, adopted, etc.) and/or other members
Client s name: Date: Legal Guardian (if minor): Form completed by: Address: City: State: Zip: Phone (home): (work):
Regan Haight, APRN Psychiatric/Mental Health Nurse Practitioner 12569 South 2700 West Suite 202, Riverton UT 84065 Phone: 801-701-1006 Fax: 801-701-1009 Email: reganhaight@gmail.com Client s name: Date: