2015 Peoples Counseling and Consulting. Improved relationships with oneself & others 4509 South 6th Street, Suite 307 Klamath Falls, Oregon 97603
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1 Improved relationships with oneself & others Peoples Counseling & Consulting 4509 South 6th Street, Suite 307 Klamath Falls, Oregon T F E counselingpeople.com W counselingpeople.com Jay Peoples MS, MSW, LCSW Name Date of Birth Gender Address City Zip code Cell Phone Home Phone Work Phone Date Age State Primary Reason for seeking services q Anger Management q Coping q Eating Disorder q Mental Confusion q Sleeping Problems q Alcohol/drugs q Anxiety q Depression q Fear/Phobias q Sexual concerns q Addictive behaviors q Other mental health concerns Family Information Mother Father Spouse Children 1 of 8
2 Significant Others (brothers, sisters, grandparents, step-relatives, half-relatives. Please specify relationship). Relationship/Name Marital Status (more than one answer may apply) q Single q Legally married q Unmarried, living together q Separated q Divorce in process q Divorced q Widowed q Annulment Total number of marriages: Assessment of current relationship (if applicable) q Good q Fair q Poor Parental Information q Parents legally married q Parents have ever been separated q Parents ever divorced q Mother remarried Number of times: q Father remarried Number of times: q Special circumstances (raised by person other than parents, information about spouse/children not living with you, etc.): Development Are there special, unusual, or traumatic circumstances that affected your development? q Yes q No If yes, please describe: Has there been any history of child abuse? q Yes q No If yes, which type(s) q Sexual q Physical q Verbal q Emotional Intake Information 2 of 8
3 Development - Continued If yes, the abuse was as a: q Victim q Perpetrator q Both Other childhood issues: q Neglect q Inadequate nutrition q Other (please specify): Comments regarding childhood development: Social Relationships Please check how you generally get along with other people: q Affectionate q Aggressive q Avoidant q Fight/argue often q Follower q Friendly q Leader q Outgoing q Affectionate q Shy/withdrawn q Submissive q Other (specify): Sexual orientation: Comments: Sexual dysfunction? q Yes q No Any current or history of being a sexual perpetrator? q Yes q No Cultural/ethnic To which cultural or ethnic group, if any, do you belong? Are you experiencing any problems due to cultural or ethnic issues? q Yes q No Other cultural/ethnic information: Spiritual/religious How important to you are spiritual matters? q Not q Little q Moderate q Much Are you affiliated with a spiritual or religious group? q Yes q No Were you raised within a spiritual or religious group? q Yes q No Would you like your spiritual or religious beliefs incorporated into the counseling? q Yes q No 3 of 8
4 Legal Current Status Are you involved in any active cases (traffic, civil, criminal)? q Yes q No If Yes, please describe and indicate the court and hearing/trial dates and charges: Are you presently on probation or parole? q Yes q No If Yes, please describe: Past History Traffic violations q Yes q No DWI, DUI, Etc. q Yes q No Criminal involvement q Yes q No If Yes, to any of the above, please fill in the following information: Charges Date Where (City) Result Education (Fill in all that apply) years of education: Currently enrolled in School? q Yes q No High School grad/ged year Graduated q Vocational Number of years Graduated q Yes q No Major: q College Number of years Graduated q Yes q No Major: q Graduate Number of years Graduated q Yes q No Major: q Other training: Special circumstances (e.g., learning disabilities, gifted): Employment Begin with most recent job, list job history: Reason left the job How often miss work? Employer Dates Title Currently q Full time q Part time q Temporary q Laid-off q Other (describe): q Disabled q Retired q Student q Social Security Military Military experience? q Yes q No Combat experience? q Yes q No Where? q Disabled q Retired q Student q Social Security Branch Discharge date Date drafted Type of discharge Date enlisted Rank at discharge 4 of 8
5 Leisure/Recreational Describe special areas of interest or hobbies (e.g., art, books, crafts, physical fitness, sports, outdoor activities, church activities, walking, exercising, diet/health, hunting, fishing, bowling, traveling, etc.) Activity How often now? How often in the past? Medical/Physical Health (Check all that apply) q AIDS q Dizziness q Nose bleeds q Alcoholism q Drug abuse q Pneumonia q Abdominal pain q Epilepsy q Rheumatic Fever q Abortion q Ear infections q STD s q Allergies q Eating problems q Seizures q Anemia q Fainting q Sleeping disorders q Appendicitis q Fatigue q Sore throat q Arthritis q Frequent urination q Scarlet Fever q Asthma q Headaches q Sinusitis q Bronchitis q Hearing problems q Smallpox q Bed wetting q Hepatitis q Stroke q Cancer q Heart Problems q Sexual problems q Chest pain q Kidney problems q Tonsillitis q Chronic pain q High blood pressure q Tuberculosis q Colds/Coughs q Mononucleosis q Toothache q Constipation q Measles q Thyroid problems q Chicken Pox q Menstrual pain q Vision problems q Dental problems q Mumps q Vomiting q Diabetes q Neurological disorders q Whooping cough q Diarrhea Nausea q Miscarriages List any current health concerns: List any recent health or physical changes: Nutrition Meal How often Typical foods eaten Typical amount eaten Breakfast ( ) times Week q No q Low q Medium q High Lunch ( ) times Week q No q Low q Medium q High Dinner ( ) times Week q No q Low q Medium q High Snack ( ) times Week q No q Low q Medium q High Comments: Current prescribed medications Dose Dates Purpose Side effects Current over-the-counter medications Dose Dates Purpose Side effects 5 of 8
6 Nutrition - Continued Are you allergic to any medications or drugs? If Yes, please describe: q Yes q No Last physical exam Date Reason Result Last doctor s visit Date Reason Result Last dental exam Date Reason Result Most recent surgery Date Reason Result Other surgery Date Reason Result Upcoming surgery Date Reason Result Family history of medical problems Please check if there have been any recent changes in the following: q Sleep patterns q Eating patterns q Behavior q Energy level q Physical activity level q General disposition q Weight q Nervousness/tension Describe changes in areas in which you checked above: Chemical Use Substance Method of use & amount Frequency of use Age of first use Age of last use Last 48 hrs Last 30 days Alcohol q Yes q No q Yes q No Barbiturates q Yes q No q Yes q No Valium/Librium q Yes q No q Yes q No Cocaine/Crack q Yes q No q Yes q No Heroin/Opiates q Yes q No q Yes q No Marijuana q Yes q No q Yes q No PCP/LSD/Mescaline q Yes q No q Yes q No Inhalants q Yes q No q Yes q No Caffeine q Yes q No q Yes q No Nicotine q Yes q No q Yes q No Over-the-counter q Yes q No q Yes q No Prescription dugs q Yes q No q Yes q No Other drugs q Yes q No q Yes q No Substance of preference: 1) 2) 3) 4) Substance Abuse Questions Describe when and where you typically use substances: Describe any changes in your use patterns: Describe how your use has affected your family or friends (include their perceptions of your use): 6 of 8
7 Substance Abuse Questions - Continued Reason(s) for use: q Addicted q Build confidence q Escape q Self-medication q Socialization q Taste Other (specify): How do you believe your substance use affects your life? Who or what has helped you in stopping or limiting your use? Does/Has someone in your family present/past have/had a problem with drugs or alcohol? q Yes q No Have you had withdrawal symptoms when trying to stop using drugs or alcohol? q Yes q No Have you had adverse reactions or overdose to drugs or alcohol? (describe): q Yes q No Does your body temperature change when you drink? q Yes q No Have drugs or alcohol created a problem for your job? q Yes q No Counseling/Prior Treatment History Information about client (past and present): (Please check one) When Where your reaction to overall experience Counseling/Psychiatric Treatment q Yes q No Suicidal thoughts/attempts q Yes q No Drug/alcohol treatment q Yes q No Hospitalizations q Yes q No Involvement with self-help (e.g., AA, Al-non, NA) q Yes q No Information about family/significant others (past and present): 7 of 8
8 Counseling/Prior Treatment History - CONTINUED (Please check one) When Where your reaction to overall experience Counseling/Psychiatric Treatment q Yes q No Suicidal thoughts/attempts q Yes q No Drug/alcohol treatment q Yes q No Hospitalizations q Yes q No Involvement with self-help (e.g., AA, Al-non, NA) q Yes q No Please check behaviors and symptoms that occur to you more often than you would like them to take place: q Aggression q Distractibility q Hopelessness q Sexual addiction q Alcohol dependence q Dizziness q Impulsivity q Sexual difficulties q Anger q Drug dependence q Irritability q Sick often q Antisocial behavior q Eating disorder q Judgment errors q Sleeping problems q Anxiety q Elevated mood q Loneliness q Suicidal thoughts q Avoiding people q Fatigue q Memory impairment q Thoughts disorganized q Chest pain q Gambling q Mood shifts q Trembling q Cyber addiction q Hallucinations q Panic attacks q Withdrawing q Depression q Heart palpitations q Phobias/fears q Worrying q Disorientation q High blood pressure q Recurring thoughts Other (specify): Briefly discuss how the above symptoms impair your ability to function effectively: Any additional information that would assist us in understanding your concerns or problems: 8 of 8
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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:
Name Age DOB Sex M F Your relationship status: Single Married Life partner Widowed Address
Today s Date Contact Information Name Age DOB Sex M F Your relationship status: Single Married Life partner Widowed Address Phone numbers and E-mail (please check numbers to call or leave a message) Home
Naturopathic & Acupuncture Intake Form (Age 14+)
Dr. Katie Thomson Aitken BAS, ND Dr. Alaina Gair, B.Sc., ND 86 Norfolk St., Guelph 519-827-0040 Contact Information Naturopathic & Acupuncture Intake Form (Age 14+) Name: Gender: Age: Birth Date (dd/mm/yy):
Byers Wellness Center- Patient Information for HCG Program. General Patient Information
1 Byers Wellness Center- Patient Information for HCG Program Welcome to Byers Wellness Center. We are excited to have you as one of our patients. In order for us to best serve you on your initial visit
EGEA MEDICAL WEIGHT LOSS CENTER. Name: Age: Sex: M F. 6. History of Diabetes? Yes No At what age:
EGEA MEDICAL WEIGHT LOSS CENTER Medical History Form Name: Age: Sex: M F Primary Care Physician: Home Phone : Present Status: 1. Are you in good health at the present time to the best of your knowledge?
Your Name: Date of Birth: Age: Address: City/State/Zip: Phone (home): (mobile): (work): Shall we add you to our e-newsletter?
Your Name: Date of Birth: Age: Address: City/State/Zip: _ Phone (home): (mobile): (work): Email: Shall we add you to our e-newsletter? Y / N Your Employer: Employer Phone: Employer Address: Your Occupation:
The information you provide us will greatly help us provide the highest quality and most comprehensive care for you.
Rheumatology (circle location of appointment) 111 Hundertmark Rd. Suite 115N 560 S. Maple St. Suite 400 place patient label here Chaska, MN 55318 Waconia, MN 55387 952-361-2450 952-361-2450 The information
Instructions for Attorneys on completing the Patient Questionnaire
Instructions for Attorneys on completing the Patient Questionnaire (please remove this cover page before providing to the questionnaire to the patient) In order to minimize the amount of time that is spent
PSYCHIATRIC INTAKE AND TREATMENT PLAN-PART I TO BE FILLED BY PATIENT PLEASE PRINT
DOB: / / / PSYCHIATRIC INTAKE AND TREATMENT PLAN-PART I TO BE FILLED BY PATIENT PLEASE PRINT Date Age Gender M F Current address: Married. Single Separated Divorced Widowed If patient is a child, he/she
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
MEDICAL HISTORY (To be filled in by patient)
MEDICAL HISTORY Reason for Visit or Chief Complaint: Referred By: Present Illness: (To be filled in by Physician) I. Have you had any reactions, allergies or bad effects from any of the following: Serum
Ageless Acupuncture Patient Health History
Ageless Acupuncture Patient Health History Name: Date: By what name would you like us to refer to you?: Street Address: City: State: Zip Code: Home Telephone: Work Telephone: Cell Phone: How early/late
Corinna Mosher, M.D. A Medical Corporation 415 E. Rolling Oaks Drive Suite #280 Thousand Oaks, CA (805) Fax (805)
Patient Registration: Corinna Mosher, M.D. A Medical Corporation 415 E. Rolling Oaks Drive Suite #280 Thousand Oaks, CA 91361 (805) 496-8522 Fax (805) 496-0469 Last Name: First Name: MI: Address: City:
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:
Pure Health Natural Medicine
Pure Health Natural Medicine Female Intake Date: Personal Information Name: (first, last) Maiden: Preferred Name: Sex: M F Date of Birth: Age: Street Address: City: State: Zip: E-mail Home Phone: Cell
Patient History Form
Patient History Form Advanced Directive Care Plan? Yes No Name: Birth date: / / Address: Age: Sex: F M STREET DAY YEAR Telephone: Home ( ) CITY STATE DAY YEAR MARITAL STATUS: Divorced Separated Alive/Age