Driftwood Psychological Services 664 Scranton Rd., Suite 201 Brunswick, GA Phone:
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- Eunice Martin
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1 1 Driftwood Psychological Services 664 Scranton Rd., Suite 201 Brunswick, GA Phone: Client name Date ADULT HISTORY FORM Presenting problems Why I came for counseling: How long have I had the problem? CURRENT SYMPTOM CHECKLIST (Rate intensity of symptoms that are currently present) 0 = This symptom is not present at this time 1 = This symptom is present, bothers me a little, but not enough to be a problem. 2 = Symptom present, bothers me and affect my quality of life, but able to function okay 3 = Moderate impact on quality of life and/or day-to-day functioning 4 = Significant impact on quality of life and day-to-day functioning 5 = Serious impact on quality of life and interferes with day-to-day functioning Symptom Severity Symptom Severity Symptom Severity Depressed mood Hearing/seeing things Thoughts of hurting myself Worrying Feel I m being watched Thoughts of killing myself Difficulty concentrating Feel others are against me Heart racing Angry feelings Loss of interest in things Twitches/spasms Angry behavior Temper outbursts Knot in stomach Feeling anxious/nervous Thoughts coming too fast Fear of places Panic attacks Trouble with memory Grinding of teeth Sweaty palms Chest pain Back pain Mind going blank Cry easily Upset stomach Poor appetite Tiredness/fatigue Easily annoyed/irritated Sleeping too much Lump in throat Sleeping too little Difficulty falling asleep Poor appetite/weight loss Difficulty staying asleep Guilty feelings EMOTIONAL/PSYCHIATRIC HISTORY Have you been in counseling before? Yes No Name of Counselor Counselor Address Counselor Phone No. Dates of service How many sessions?
2 2 Has any family member seen a counselor? Yes No Which family member? Relationship to you What was counseling for? Were you ever in the hospital for a psychiatric or substance use disorder? Yes No Name of facility City and state of facility Facility phone number Admission date For how long? Has any family member been hospitalized for a psychiatric or substance use disorder? Yes No Which family member? Relationship to you What was the hospital stay for? Do you take any medication(s)? Yes No If yes, what medication(s) and for which condition(s)? Has any family member used psychiatric medication(s)? Yes No If yes, who/what/why (list all): which condition(s)? Emotional health problems of family: (check all that apply) Mother Father Sister Brother Aunt Uncle Children Grandparents Alcohol/drugs Anxiety Attention Deficit Bipolar Disorder Depression Eating Disorder Post-traumatic stress Schizophrenia Suicide attempt FAMILY HISTORY
3 3 Describe childhood family experience (circle all that apply): Outstanding, warm, supportive Normal, adequate, average Inconsistent or chaotic environment Witnessed physical/emotional/sexual abuse Experienced physical/emotional/sexual abuse Age of emancipation from home: Circumstances: Special circumstances during childhood: MY MARITAL STATUS Not currently in a relationship People living in my household Single, never married Never been in a serious relationship Name Age Sex Rel. to me Engaged months Currently in a serious relationship Marriage #1 years Currently living with a partner Marriage #2 years Happy with current relationship Marriage #3 years Current relationship needs work Marriage #4 years Unhappy with current relationship Divorce/breakup #1 year: Reason: Divorce/breakup #2 year: Reason: Divorce/breakup #3 year: Reason: Divorce/breakup #4 year: Reason: Children who do not live with me (names/ages): Describe any past or current significant issues in intimate relationships: Describe any past or current significant issues in other immediate family relationships: RELIGION/SPIRITUALITY No Yes Do you feel that you have a purpose in life? Do you believe in a power greater than yourself? Do you feel that your morals, beliefs and values have been compromised due to alcohol/drug use? Were you raised with a religion as a child? If yes, what denomination? Do you currently practice any spiritual activities such as praying, attending church, member of choir, reading, mass, meditation, journal? If yes, list activities: Briefly describe what the word God means to you:
4 4 Medical history Describe current health: [ ] Good [ ] Fair [ ] Poor Name of personal physician: Address: Phone number: Name of psychiatrist (if any) : Address: Phone number: Date of last physical exam: List any abnormal test results: Describe any serious hospitalizations or accidents: Date Age Reason Date Age Reason Date Age Reason Is there a history of any of the following in the family? (check all that apply) [ ] Tuberculosis [ ] Birth defects [ ] Emotional problems [ ] Behavioral problems [ ] Thyroid problems [ ] Cancer [ ] Heart disease [ ] Diabetes [ ] Mental retardation [ ] High blood pressure [ ] Alzheimer s/dementia [ ] Stroke [ ] Drug abuse [ ] Alcoholism [ ] Other chronic or serious health problems List any health problems currently being treated or have been treated in the past: Chronic pain problems Choose a number from 0-10 that best describes your pain : (no pain) (maximum pain) Where is the pain located? How long have you had the pain? When did the pain start? How often do you experience pain? Does the pain affect activities (e.g., walking, shopping, exercise, etc.)? What makes the pain worse? What lessens the pain?
5 5 Addiction history Father Mother Sister Brother Aunt Uncle Cousin Grandmother Grandfather Spouse or partner Children Currently using/abusing (list substances used) Used/abused, quit (check if applies) Did/health problems due to use Self Age at first use Used in past 6 months Alcohol prefer [ ] Beer [ ] Wine [ ] Liquor Amphetamines / Meth / Speed Barbiturates / Downers Cocaine / Crack Hallucinogens (LSD, mushrooms, acid) Inhalants (paint, glue, gas) Marijuana PCP Painkillers (morphine / heroin / Oxcycontin) Steroids Prescription drugs Other: Check all circumstances that apply to you regarding your use of drugs and/or alcohol: [ ] Used to sleep [ ] Relieve emotional pain [ ] Relieve anxiety [ ] To avoid withdrawal [ ] To get rid of hallucinations [ ] Used to relax [ ] Relieve physical pain [ ] Relieve anxiety [ ] To function socially [ ] Morning Use [ ] Used alone Consequences of substance use: [ ] Hangovers [ ] Withdrawal symptoms [ ] Loss of control of amount used [ ] Binges [ ] Seizures [ ] Medical conditions [ ] Assaults [ ] Job loss [ ] Blackouts [ ] Tolerance changes [ ] Suicidal impulses [ ] Arrests [ ] Overdose [ ] Sleep disturbance [ ] Relationship conflicts [ ] Legal problems Treatment history: [ ] Outpatient [ ] Inpatient [ ] 12-step program [ ] Stopped on own No Yes [ ] [ ] Has anybody complained about your substance use? Who? _ [ ] [ ] Have you ever received a DUI? If yes, how many? Dates [ ] [ ] Have you had any other legal problems where alcohol or drugs were involved? If yes, explain
6 6 No Yes [ ] [ ] Have you ever awakened the morning after using substances the night before and found that you could not remember part of the evening before? [ ] [ ] Have you ever gone for more than three days without using substances without a struggle? [ ] [ ] Did you ever need a drink first thing in the morning to get started? [ ] [ ] Have you had any of the following problems when you stopped or cut down on your substance use? (check all that apply) [ ] Shakes [ ] Seeing or hearing things that aren t there [ ] Heavy sweating, heart beating fast [ ] Unable to sleep [ ] Feeling anxious or depressed [ ] DT s or seizures [ ] [ ] Have you ever used substances to keep from having withdrawal symptoms or to make them go away? [ ] [ ] Did you continue to use substances, knowing it caused you to have health problems or injuries? [ ] [ ] Have you ever continued to use substances while taking medication that was dangerous to take with that substance? [ ] [ ] Have substances ever caused you to feel: [ ] disinterested in things [ ] depressed [ ] paranoid [ ] [ ] Did these problems cause you to cut down on substance use? [ ] [ ] Have you ever spent a lot of time getting, using, or getting over the effects? [ ] [ ] Have there been many days when you used much larger amounts of substances than you intended to when you began? [ ] [ ] Have you tried to cut down on your substance use but found that you couldn t? [ ] [ ] Did you ever feel sick because you stopped or cut down on substance use? [ ] [ ] Have you ever felt you needed larger amounts of substances to get the same effect as before? [ ] [ ] Have substances caused problems with your family, friends, workers, or with the police? [ ] [ ] Have you given up, or greatly reduced, important activities such as sports, work, or associating with friends or relatives in order to use substances? Self-Evaluation: Personal Strengths Personal Weaknesses
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INTAKE FORM CONFIDENTIAL Name Today s Date Contact information: Date of birth Address: City: State: Zip: Phone number (cell): (home): (work): Email address: May I leave a voicemail on your cell or home
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6800$5< /,)(7,0( ',$*126(6 &+(&./,67 'DWH RI &XUUHQW BBBB BBBB BBBBBB
Criteria for Probable Diagnosis: 1. Meets criteria for core symptoms of the disorder. 2. Meets all but one, or a minimum of 75% of the remaining criteria required for the diagnosis 3. Evidence of functional
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