ANXIETY & OCD TREATMENT CENTER OF ANN ARBOR CLIENT INFORMATION - ADULT
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1 ANXIETY & OCD TREATMENT CENTER OF ANN ARBOR CLIENT INFORMATION - ADULT Client s Name Name you go by (if different) Gender Age Date of Birth Address City State Zip OK to leave a message? Y/N Y/N Home Phone Cell Phone Y/N Work Phone Best number to reach you? Home Cell Work OK to leave a message? Occupation Employer Address (If you wish to communicate with your clinician about scheduling or share other information via , please list your address above. Doing so indicates your permission for me to communicate with you via as well as your acknowledgement that the security of electronic communication cannot be guaranteed. All communication will become part of your record.) In case of emergency, whom do I have permission to contact? Name Phone Number Relation to client? PRIMARY INSURANCE INFORMATION Insurance Company Policy Holder Contract # Policy Holder s Social Security Number Group # Policy Holder s DOB Employer Policy Holder s Relationship to Client
2 PSYCHOLOGICAL SYMPTOMS AND HISTORY pg 2 Please check any of the following that are currently bothering you: Worrying too much Feeling tense Feeling fearful Panic attacks Startle easily Trauma/abuse Being scared for no reason Worrying what others think about me Having to redo things or check things Doing things very slowly to Financial problems Sexual problems Infertility Trouble concentrating Easily distracted Memory problems Racing thoughts Procrastination Careless mistakes Start but don t finish tasks Irritability/easily annoyed Sadness Problems staying asleep Fatigue/feeling tired Nightmares Appetite change Self injury Excessive spending Impulsivity Hyperactivity Seeing/hearing things that other people don t see/hear Feeling something is wrong with your mind Someone s death My weight My eating Purging Food restriction Hair-pulling Skin-picking Gambling Sexual addiction Internet addiction Upset Stomach Headaches make sure they are correct Crying easily Feeling disoriented Chronic Pain Unwanted thoughts Hopelessness Feeling high without being Anger Avoiding things I am Worthlessness on drugs Being violent afraid of Low self-confidence Mood swings Homicidal thoughts Asking others for Feeling inferior Feeling numb Other: reassurance Low energy level My feelings being easily Couples problems Difficulty making decisions hurt Family problems Feeling confused Difficulty controlling Problems with children Loss of interest/pleasure thoughts Difficulty making friends Thoughts of suicide Difficulty controlling Withdrawing Increased sleep actions Please note: Substance use Loneliness Decreased sleep Being suspicious of others concerns are explored in detail Work/school problems at the end of this packet Problems falling asleep Additional symptom questions For each item, check the response that best describes you in the last 6 months 1) I worry too much about different things 2) I find that I am not able to stop or control worrying 3) I have trouble falling or staying asleep, or have restless and unsatisfying sleep 4) Unusual body sensations scare me Never Rarely Sometimes Often All the time 5) I have experienced repeated or unexpected attacks during which I am suddenly overcome by intense fear or discomfort for no apparent reason 6) If yes to #5, are you concerned about this attack happening again? 7) I have avoided places or activities that may trigger intense feelings of anxiety or panic (crowds, public places, driving, exercising or hot showers) 8) I have little interest or pleasure in doing things 9) I often feel down, depressed, or hopeless 10) I find myself worrying that I won t know what to say in social situations 11) I have difficulty doing daily activities in front of others including talking, eating, writing or making eye contact. 12) I am frequently bothered by unpleasant thoughts or images that repeatedly enter my mind (ie. Violent or sexual images and thoughts)
3 Additional symptom questions (continued). For each item, check the response that best describes you in the last 6 months 13) I have frequent, unwanted thoughts that seem uncontrollable Never Rarely Sometimes Often pg3 All the time 14) I feel the need do things over and over again even though I know it is excessive to reduce my anxiety 15) I feel compelled to engage in rituals or repetitive behaviors that take a lot of time in my day 16) I feel persistent and unreasonable fear of an object or situation such as flying, heights, small spaces, animals, blood etc. 17) It is important to me to stay in control of my emotions. 18) I worry more than most people I know about having a serious illness, disease, or medical condition 19) I am very aware of sensations occurring in my body, and notice many aches, pains, and/or other symptoms of what I think may be illnesses, diseases, or medical conditions. 20) I have experienced or witnessed an event in my past that was extremely scary, horrifying, assaulting, and/or life-threatening 21) I have recurrent and distressing memories of that event even when I try not to think about it PREVIOUS COUSELING/PSYCHOTHERAPY Have you been seen previously for treatment or evaluation of psychological or psychiatric concerns? Yes No Check if applicable: Inpatient Day Treatment Substance Abuse Program Outpatient Psychological Testing Psychiatric Evaluation Partial Hospitalization Name of Facility and/or Provider Dates Problem Area Was it helpful? Have you Made a suicide attempt(s)? Yes No Felt suicidal in the past? Yes No Had episodes of explosive anger? Yes No Do you currently have homicidal/suicidal feelings? Yes No Please describe: Abuse/Trauma Have you been physically abused or assaulted sexually abused, molested or assaulted emotionally or verbally abused a victim of or witness to a life-threatening event Comments Family Mental Health Have any of your immediate family members had mental health problems (anxiety, depression, substance use, suicide, etc)? Yes No If yes, please describe
4 HEALTH INFORMATION pg 4 Physician: Current on immunizations? Y N Date of Last Physical/Annual Exam: Are you pregnant? Y N If yes, # weeks: How is your health in general? Excellent Good Have you had miscarriage(s)? Y N Fair Poor Other: Check any of the following that you have had or currently have: Major accident/injury Hospitalization Surgery Adverse medication reaction Allergies Anemia Angina Arthritis Asthma Birth defects Bladder problems Blood pressure (high/low) GI problems Cancer Cerebral Palsy Chronic fatigue Dental problems Diabetes Epilepsy Fibromyalgia Head trauma (loss of consciousness? Y N) Headaches Please provide additional detail about items checked above: Hearing problem Heart disease Hepatitis A B or C Hypoglycemia Huntington s Kidney problems Learning Disability Liver problems Lung condition Menopause Multiple Sclerosis Parkinson s Disease Speech/language problem Stroke Thyroid (Hypo/Hyper) Ulcer Vision problem Other (please list): Do you have any disabilities not noted thus far? Y N If Yes, please describe: Please list all current prescribed &/or over-the-counter medications/supplements. (If none, check this box ) Medication Dosage Prescribed by Medication Dosage Prescribed by If you listed psychiatric medications above, do they seem to be helping? No A little Moderately A lot Please list any psychiatric medications you recall using in the past:
5 FAMILY INFORMATION pg 5 Marital Status Single Partnered/Cohabitating Married Separated Divorced Widowed Other Please list people currently living with you Name Relationship Age Satisfied with Comments to you relationship? (Y/N) Please list children not living with you. (If you have any deceased children, please write deceased and age at time of death.) Name Age Lives with Satisfied with relationship? (Y/N) Comments Please list members of your family of origin (parents, siblings, step-family, etc) that are not listed above. Name Relationship Age (if deceased, write Satisfied with Comments to you deceased and age at death) relationship? (Y/N) Your place of birth: Ethnic identification African American Caucasian Native American Hispanic Latino Asian Other (please specify): Were you adopted? Yes No Sexual Identification Straight Gay/Lesbian Bisexual Other Friendships No friends Only acquaintances Acquaintances & friends Are you satisfied with your friendships? Yes No Do you have sufficient social support? Yes No Previous Relationships Please list previous significant relationships (e.g., dissolved marriages, partnerships, etc). If not applicable, check this box
6 EDUCATIONAL & VOCATIONAL INFORMATION pg 6 Schools/colleges attended School/College Name Diploma/Degree Area of Study Employment History Job Organization Length of Time Satisfied with Job? Reason for Leaving Military Service Yes No If yes, please specify rank branch saw combat? Discharge year: Honorable discharge? Yes No RELIGION/SPIRITUALITY Protestant Catholic Jewish Buddhist Hindu Muslim Agnostic Atheist Other Presently active in religion/spirituality? Yes No N/A Satisfied with religion/spirituality? Yes No N/A LEGAL INFORMATION Have you (currently and/or or in past): If any legal difficulties, please describe: Had difficulty or contact with police? Been convicted of a crime? Been on Probation? No history of legal problems LEISURE ACTIVITIES Please list your leisure activities (hobbies, activities used for stress relief, tasks you enjoy in your spare time): Are you satisfied with these activities (e.g., frequency, enjoyment, etc)? Yes No
7 SUBSTANCE USE: Please complete the chart below and circle any of the substances listed if you have used them in the past 48 hours. pg7 Category of Substance Current Use? Ever used? Please complete these questions for substances you currently use How often do Use has Don t Others Have you have a led to do express tried to strong urge to problems what s concern cut use? (hourly, (social, expecte about my down or daily, every health, d of me use stop other day, legal, due to etc) work) use Amount and Frequency of Use (e.g., 8 beers/day) Alcohol N Y N Y N Y N Y N Y N Y N Y Stimulant N Y N Y N Y N Y N Y N Y N Y Cocaine N Y N Y N Y N Y N Y N Y N Y Tranquilizer N Y N Y N Y N Y N Y N Y N Y Barbiturate N Y N Y N Y N Y N Y N Y N Y Marijuana N Y N Y N Y N Y N Y N Y N Y Opioid N Y N Y N Y N Y N Y N Y N Y Hallucinogen N Y N Y N Y N Y N Y N Y N Y Prescribed N Y N Y N Y N Y N Y N Y N Y Nicotine N Y N Y N Y N Y N Y N Y N Y Caffeine N Y N Y N Y N Y N Y N Y N Y Withdrawal symptoms Other N Y N Y N Y N Y N Y N Y N Y Specify Drug / Alcohol of Preference: Do you use Drugs / Alcohol in combination? No Yes If yes, describe: Ever treated for alcohol or drug poisoning? No Yes Number of blackouts: Twelve Step (e.g., Alcoholics Anonymous) or other addiction group attended? No Yes ************************************************************************************************ Is there any other information that you would like us to know?
CLIENT QUESTIONNAIRE. Preferred Name: Address: (Street) (City/State) (Zip Code) Home Phone: Cell Phone: Relationship: Cell Phone:
CLIENT QUESTIONNAIRE Full Legal Name: DOB: / / Preferred Name: Email: Address: (Street) (City/State) (Zip Code) Home Phone: Cell Phone: Can we leave voice messages for you at these numbers? Yes Text Messages?
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Client s Name: Today s Date: Partner s Name (if being seen as a couple): Address, City, State, Zip: Home phone: Work phone: Cell phone:
Client s Name: Today s Date: Partner s Name (if being seen as a couple): Address, City, State, Zip: Home phone: Work phone: Cell phone: Private email address: Student? If yes, where and major? May we leave
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Demographic Information Form
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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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Adult Information Form Page 1
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Anxiety Depression Sleep problems Thoughts of suicide. Panic Unusual thoughts Anger outbursts Changes in weight
Client Information Name: Biographical Information Please complete this form, which will provide information useful in treatment. If you are not the patient (for example, if you are giving information about
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LIFE HISTORY QUESTIONNAIRE Adult The purpose of this questionnaire is to obtain an understanding of your life experience and background. Then we can begin to develop a comprehensive treatment program suited
SECTION 2: CURRENT CONCERNS Briefly describe the current concerns you would like to discuss with your counselor:
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Westminster IAPT Primary Care Psychology Service. Opt-In Questionnaire
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Elana Klemm, LPC, NCC Compassionate Care Counseling 4343 Shallowford Rd. Suite H-1B Marietta, GA ( ) NEW CLIENT INFORMATION
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Counseling Associates, Inc.
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PERSONAL HISTORY NAME TODAY S DATE LAST FIRST MI LIST ANY ADDITIONAL NAMES USED: ADDRESS PHONE (STREET) (CITY) (STATE) (COUNTY) (ZIP)
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Part I. Demographics. Part II. Presenting Problem. Who referred you to WellStar Psychological Services?
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Les Fehmi, Ph.D. 317 Mt. Lucas Road Princeton NJ 08540 609.924.0782 Fax: 609.924.0782 lesfehmi@openfocus.com www.openfocus.com Date: Interviewer: Referred By: 1. NAME: MALE/FEMALE BIRTH DATE: / / 2. ADDRESS:
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CHECKLIST OF CONCERNS AND HISTORY FORM
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problems/medications: Current supplements/vitamins/herbs: Past medical problems/medications: Other doctors/clinics seen regularly:
Main Purpose of the consultation (Please give a brief summary of the main problems) What happened to make you seek evaluation at this time? MEDICAL HISTORY Current medical Prior Attempts to correct the
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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
Medications. New Patient Registration. Billing and Insurance. Phone Calls. Prescription Refills. Lab Results and Test Results
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