ADOLESCENT INFORMATION FORM

Transcription

1 ADOLESCENT 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. If certain questions do not apply to you, mark them as N/A. Name: SS #: Birth date: Address: Phone: (home): Date: Gender: M F Age: (cell): Emergency contact: Telephone number: Relationship: Primary reason(s) for seeking services at this time: How did you hear about Sauder Psychology? Family Information Family You Are Growing Up In (Include significant others, grandparents, step-relatives) Living Living with you Name and Relationship Age Yes No Yes No Partner Status (more than one answer may apply) Single Dating Living with Partner Married Assessment of current relationship (if applicable): Good Fair Poor Parental Information Parents legally married Parents ever separated Parents ever divorced Mother remarried: Number of times : Father remarried: Number of times: Development Are there special, unusual, or traumatic circumstances that affected your development? Yes No If Yes, please describe: Has there been a history of child abuse: Yes No If yes, which type(s)? Sexual Physical Verbal Emotional If Yes, the abuse was as a: Victim Perpetrator Other childhood issues: Neglect Inadequate nutrition Other

2 Comments regarding childhood development: Which of the following best describes your family? Warm and accepting Average Hostile / fighting Which of the following best describes the way in which your family is raising you? Allowed me to be Attempted to very independent Average control me What is your mother s occupation? What is your father s occupation? Social Relationships Check how you generally get along with other people: (check all that apply) Affectionate Aggressive Avoidant Fight/argue often Follower Friendly Leader Outgoing Shy/withdrawn Submissive Other (specify): Sexual orientation: Sexual problems? Yes No Comments: Is your house troubled by domestic violence? Yes No If Yes, please explain: Does any family member have an alcohol or drug problem? Yes No If Yes, please explain: Cultural/ Ethnic To which cultural or ethnic group do you belong? Are you experiencing any problems due to cultural or ethnic issues? Yes No Spiritual/ Religious How important to you are spiritual matters? Not Little Moderate Much Are you affiliated with a spiritual or religious group? Yes No Would you like your spiritual/religious beliefs incorporated in this counseling? Yes No Legal Current Status Are you involved in any active cases (traffic, civil, criminal)? Yes No If Yes, please describe and indicate the court and hearing/trial dates and charges: Are you presently on probation or parole? Yes No If Yes, please describe:

3 Past History Traffic violations: Yes No DWI, DUI, etc.: Yes No Criminal involvement: Yes No Civil involvement: Yes No Education Years of education: Currently enrolled in school? Yes No High school grad/ged Vocational:Number of years: Graduated: Yes No Major: College: Number of years: Graduated: Yes No Major: Other training: Special circumstances (e.g., learning disabilities, gifted): Employment Begin with most recent job, list job history: Employer Dates Title Reason left job How often miss work? Currently: FT PT Social Security Leisure/Recreational Describe special areas of interest or hobbies (e.g., art, fishing, books, physical fitness, sports, crafts, outdoor activities, church activities, diet/health, hunting, bowling, traveling, etc.) Activity How often now? How often in the past? Medical/Physical Health List any current health concerns: List any recent health or physical changes: Nutrition Meal How often Typical foods eaten Typical amount eaten (times per week) Breakfast /week No Low Med High Lunch /week No Low Med High Dinner /week No Low Med High Snacks /week No Low Med High Comments: Current prescribed medications Dose Dates Purpose Side effects Current over-the-counter meds Dose Dates Purpose Side effects Are you allergic to any medications or drugs? Yes No

4 Last physical exam Last doctor s visit Most recent surgery Other surgery Upcoming surgery Date Reason Results Family history of medical problems: Please check if there have been any recent changes in the following: Sleep patterns Eating patterns Behavior Energy level Physical activity level General disposition Weight Nervousness/tension Describe changes in areas in which you checked above: Chemical Use History Alcohol Barbiturates Valium/Librium Cocaine/Crack Heroin/Opiates Marijuana PCP/LSD/Mescaline Inhalants Caffeine Nicotine Over the counter Prescription drugs Other drugs Method of Frequency Age Age Used in last Used in last use and of use of first of last 48 hours 30 days amount use use Yes No Yes No Substance of preference Describe when and where you typically use substances: Describe any changes in your use patterns: Reason(s) for use: Addicted Build Confidence Escape Self-medication Socialization Taste Other (specify): How do you believe your substance use affects your life? Does/Has someone in your family present/past have/had a problem with drugs or alcohol? Yes No Have you had withdrawal symptoms when trying to stop using drugs or alcohol? Yes No

5 Have you had adverse reactions or overdose to drugs or alcohol? (describe): Does your body temperature change when you drink? Yes No Have drugs or alcohol created a problem for your job? Yes No Have drugs or alcohol created a problem for your family? Yes No Counseling/Prior Treatment History Information about Yourself (past and present): Your reaction Yes No When Where to overall experience Counseling/Psychiatric treatment Suicidal thoughts Suicide attempts Drug/alcohol treatment Hospitalizations Involvement with self-help groups (e.g., AA, Al-Anon, NA Overeaters Anonymous) Information about family/significant others (past and present): Their reaction Yes No When Who to overall experience Counseling/Psychiatric treatment Suicidal thoughts Suicide attempts Drug/alcohol treatment Hospitalizations Involvement with self-help groups (e.g., AA, Al-Anon, NA Overeaters Anonymous) List and describe your greatest strengths: List and describe your greatest weaknesses: Any additional information that would assist in understanding your concerns or problems: Do you feel suicidal at this time? Yes No If Yes, explain: What are your goals for therapy?

6 DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure Child Age Name: Age: Sex: Male Female Date: Instructions: The questions below ask about things that might have bothered you. For each question, circle the number that best describes how much (or how often) you have been bothered by each problem during the past TWO (2) WEEKS. None Not at all Slight Rare, less Mild Several days Moderate More than half the days than a day During the past TWO (2) WEEKS, how much (or how often) have you or two I. 1. Been bothered by stomachaches, headaches, or other aches and pains? II. III. 2. Worried about your health or about getting sick? Been bothered by not being able to fall asleep or stay asleep, or by waking up too early? Been bothered by not being able to pay attention when you were in class or doing homework or reading a book or playing a game? Severe Nearly every day IV. 5. Had less fun doing things than you used to? V. & VI. 6. Felt sad or depressed for several hours? 7. Felt more irritated or easily annoyed than usual? 8. Felt angry or lost your temper? VII. 9. Started lots more projects than usual or done more risky things than usual? 10. Slept less than usual but still had a lot of energy? VIII. 11. Felt nervous, anxious, or scared? IX. X. 12. Not been able to stop worrying? Not been able to do things you wanted to or should have done, because they made you feel nervous? Heard voices when there was no one there speaking about you or telling you what to do or saying bad things to you? Had visions when you were completely awake that is, seen something or someone that no one else could see? Had thoughts that kept coming into your mind that you would do something bad or that something bad would happen to you or to someone else? Felt the need to check on certain things over and over again, like whether a door was locked or whether the stove was turned off? Worried a lot about things you touched being dirty or having germs or being poisoned? Felt you had to do things in a certain way, like counting or saying special things, to keep something bad from happening? In the past TWO (2) WEEKS, have you XI. 20. Had an alcoholic beverage (beer, wine, liquor, etc.)? Yes No XII. 21. Smoked a cigarette, a cigar, or pipe, or used snuff or chewing tobacco? Yes No Used drugs like marijuana, cocaine or crack, club drugs (like Ecstasy), hallucinogens (like LSD), heroin, inhalants or solvents (like glue), or methamphetamine (like speed)? Used any medicine without a doctor s prescription to get high or change the way you feel (e.g., painkillers [like Vicodin], stimulants [like Ritalin or Adderall], sedatives or tranquilizers [like sleeping pills or Valium], or steroids)? In the last 2 weeks, have you thought about killing yourself or committing suicide? Yes No Yes No Yes No 25. Have you EVER tried to kill yourself? Yes No Highest Domain Score (clinician) Copyright 2013 American Psychiatric Association. All Rights Reserved. This material can be reproduced without permission by researchers and by clinicians for use with their patients.

7 The Personality Inventory for DSM-5 Brief Form (PID-5-BF) Child Age Name: Age: Sex: Male Female Date: Instructions: This is a list of things different people might say about themselves. We are interested in how you would describe yourself. There are no right or wrong answers. So you can describe yourself as honestly as possible, we will keep your responses confidential. We d like you to take your time and read each statement carefully, selecting the response that best describes you. Very False or Often False Sometimes or Somewhat False Sometimes or Somewhat True Very True or Often True 1 People would describe me as reckless. 2 I feel like I act totally on impulse. 3 Even though I know better, I can t stop making rash decisions. 4 I often feel like nothing I do really matters. 5 Others see me as irresponsible. 6 I m not good at planning ahead. 7 My thoughts often don t make sense to others. 8 I worry about almost everything. 9 I get emotional easily, often for very little reason. 10 I fear being alone in life more than anything else. 11 I get stuck on one way of doing things, even when it s clear it won t work. 12 I have seen things that weren t really there. 13 I steer clear of romantic relationships. 14 I m not interested in making friends. 15 I get irritated easily by all sorts of things. 16 I don t like to get too close to people. 17 It s no big deal if I hurt other peoples feelings. 18 I rarely get enthusiastic about anything. 19 I crave attention. 20 I often have to deal with people who are less important than me. 21 I often have thoughts that make sense to me but that other people say are strange. 22 I use people to get what I want. 23 I often zone out and then suddenly come to and realize that a lot of time has passed. 24 Things around me often feel unreal, or more real than usual. 25 It is easy for me to take advantage of others. Total/Partial Raw Score: Prorated Total Score: (if 1-6 items left unanswered) Clinician Use Item score Average Total Score: Krueger RF, Derringer J, Markon KE, Watson D, Skodol AE. Copyright 2013 American Psychiatric Association. All Rights Reserved. This material can be reproduced without permission by researchers and by clinicians for use with their patients.