New Client Questionnaire: (rev. 08/2016)
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- Kelly Owen
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1 New Client Questionnaire: (rev. 08/2016) Client Name: Date of Birth: / / Date of First Session: / / What events or concerns brought you to my office? What goals would you like to accomplish? Are there any big changes/events you have been experiencing in your life? Current relationship status and previous marriages, divorces, or separations: Length of marriages, divorces, separations: Who else lives in your household? (Names, relationship to you, ages): Do you have other primary family members who do NOT live with you? (siblings, children) Number of close friends: With whom do you spend most of your free time? Friends Family Alone Religious/Spiritual orientation/identity: Spiritual issues? Anger Grief Sadness Shame/Guilt Emptiness Forgiveness Other: Family of Origin: Father/Age/Relationship: Father s vocational history: Mother/Age/Relationship: Mother s vocational history:
2 History and relationships with siblings and extended family: Please describe your relationship with your own children: Significant events in your family history (divorce, death, incarceration, illness): Any family history of substance abuse or mental health issues? Treatment or hospitalization? Who are your positive supportive relationships, currently? PHYSICAL HEALTH Current symptoms: Asthma Cancer Diabetes Hypertension Arthritis Insomnia Bleeding Allergies: Chronic Illness: Other: Significant Health History: Injuries/Surgeries/Conditions: Date of last physical exam: Physician: Current level of physical activity: Current level of healthy diet: Any prenatal or developmental interruptions or problems? Sexual identity: Hetero Gay Bisexual Queer Transgender Male Female
3 Current medications (include OTCs): Medication Purpose Dosage Frequency MENTAL HEALTH: Please provide details for any yes answers to the following questions: Current mental health symptoms: Are you having any thoughts of suicide or homicide (last 30 days)? Have you had any thoughts of suicide or homicide in the past? Any attempts at suicide or self-harm? Have you ever had a plan to commit suicide? Have you experienced serious depression, sadness, or hopelessness? Have you experienced serious anxiety? Do you see or hear things that others do not see or hear? Have you experienced physical, sexual, psychological, spiritual, or emotional abuse/violence? Are there other traumatic events in your history?
4 Do you now have trouble controlling violent behavior? Have you ever had trouble controlling violent behavior? Are you currently having any trouble performing activities of daily living? Please tell me about any previous mental health treatment or counseling? Do you have any previous mental health diagnoses? ACADEMIC/WORK HISTORY: Last grade completed: Any learning difficulties? Any Speech, language, hearing, visual functioning difficulties? Future Plans: Do you own a vehicle and driver s license? Periods of unemployment? Current job and employment information: Obstacles to attainment of goals: LEGAL HISTORY: Offenses against you, the client? History of legal issues, arrests, or convictions? Incarcerations? Status Offenses?
5 Violence or Assault to others? Other (please circle) : DUI Shoplifting Drug related Weapons Prostitution Vandalism Burglary Robbery Sex Crimes Major Driving Violations Other: SUBSTANCE ABUSE: Major life events prior to problematic use? Periods of Abstinence (when and why) Last use? Do you believe you have an addiction? Influences on current use: Experiences (circle please): Detox Overdose Sweats Shakes Convulsions Seizures DTs Hallucinations Passing Out Hangovers Memory Loss Blackouts Other: Other addictive behaviors? (Gambling, sex, porn, video gaming,, eating, risk taking ) Consequences of Use: Legal relational family financial career other First use Last use Frequency Form Reason Life events Tobacco Alcohol Marijuana Cocaine Meth/Amph Opiod Prescription Family Usage and treatment history: Client Treatment History: (Include education, evals, in- and out-patient treatment or counseling, and 12- step activity): Personal strengths and limitations:
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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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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
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.