Preferred Name (s): Local Address: City: State: Zip: Permanent Address: City: State: Zip: Years of Education: Occupation: Gender: M F

Transcription

1 Today Date: Client Name(s) : Psychological Consultants Northgate Center 1210 ½ -7 th Street NW, Suite 216 Rochester, MN Office: (507) Fax: (507) Preferred Name (s): Local Permanent Home Phone: Work Phone: Cell Phone: Social Security #: Date of Birth: Age: Years of Education: Occupation: Gender: M F Employer s Name: Marital Status: Employer s Insurance Information: Primary Insurance Name: Policy ID #: Primary Ins. Policy Holder s Social Security #: Policy Holder s Date of Birth: Secondary Insurance Name: Policy ID #: Secondary Ins. Policy Holder s Social Security #: Policy Holder s Date of Birth: Payment Options: How do you intend to pay for your services today? Credit Card Cash Check Credit Card Type: Credit Card Number: Name exactly as it appears on credit card (please print): Credit Card Expiration Date (mm/yy): Authorized Signature: How did you hear of us? Referred by? 1

2 Name: TWO PEOPLE TO CONTACT IN CASE OF EMERGENCY Relationship to you: Home Phone: Work Phone: Cell Phone: * Does this person know of this visit? Yes No Name: Relationship to you: Home Phone: Work Phone: Cell Phone: * Does this person know of this visit? Yes No ** In the event of an emergency, do I have permission to contact these individuals? Yes No MEDICAL INFORMATION Primary Care Physician: Address: Date of Last Physical Exam: Treating facility: Allergies: Chronic Physical Conditions: Current Medication(s)(if not enough room, list on back of page): Have you ever been treated for a serious illness, injury or head trauma? Yes No If yes, please explain: Circle any medical problems you are currently experiencing: Arthritis Heart Disease Lung Disease Stroke Asthma Heartburn Menopause Sexual Difficulties Bladder problems High Blood Pressure Osteoporosis Seizures Cancer High Cholesterol Other Male/Female Skin Disease/Disorder Diabetes: Type I/II HIV Positive Disease Thyroid Problems Other: Glaucoma Irregular Periods Polycystic Ovary Headaches Kidney Disease Disease Tuberculosis Head Injury Kidney Problems Stomach Problems Ulcer 2

3 PREVIOUS PSYCHOLOGICAL EVALUATIONS, COUNSELING, OR TREATMENTS Treating Provider: Dates of service From: To: Reason(s): Was it Helpful? Yes No If not, why? Treating Provider: Dates of service From: To: Reason(s): Was it Helpful? Yes No If not, why? Personal History What is your mother s name: Is she still alive? Yes No What is your father s name: Is he still alive? Yes No What is your parents marital status? Married Separated Divorced If your parents are separated or divorced, how old were you when they separated/divorced? Where and by whom were you raised? List the first names and ages of your siblings: Name Age Describe how it was/is growing up in your family: What one word best describes your family when you were a child? How many people currently live in your household (including yourself)? How many children do you have? List the first names and ages: Name Age Please describe the problem(s) for which you are seeking help: 3

4 When and how did your current problem(s) begin? From the list below, circle all problem areas that pertain to you at this time: Academic/School Eating Disorder Intimacy Parenting Alcohol Use Employment Legal Physical Health/Disability Anger Family Conflict Marital/Relationship Religious/Spiritual Concerns Anxiety Financial Mental Health/Disability Sexuality Criminal Behavior Gambling Mental Illness Socialization Drug Abuse Grief/Loss Mood Victim of Abuse Other: Please circle all of the symptoms you have experienced in the last two weeks. Depressed mood Irritable/Angry Shortness of breath Violent when angry Muscle tension Trouble keeping Increased worry Decreased mood Change in appetite Friends Over eating Trouble forming Sleep problems Feeling worthless Sweating friendships Loss of energy Feeling defensive Easily Distracted Angry outbursts Mind going blank Unable to follow Feeling restless Repetitive thoughts Trembling/shaking through with goals Trouble performing job Feeling anxious Dizziness Feeling numb Avoiding certain foods Seeing things others Elevated mood Racing heart Feeling hopeless don t see Hearing voices Trouble Concentrating Tire easily Thoughts of death Feeling suspicious Binging Trouble making Feeling rageful Mood swings decisions Nausea/Stomach Distress Repetitive behaviors Angry Outbursts Excessive exercise Decreased need for Racing thoughts Impulsiveness Feeling stressed sleep Restricting food Feeling Paranoid More talkative Using diuretics 4

5 Have you ever attempted suicide? Yes No If yes, list at what age(s): Are you currently feeling Suicidal? Yes No Please enter check marks where appropriate to indicate family members who have experienced mental health concerns. Depression Anxiety Alcoholism Schizophrenia Bipolar Disorder Drug Addiction Illness Self Father Mother Brother/Sister Grandparent Other Attention Deficit Disorder Eating Disorder Post-Traumatic Stress Obsessive/Compulsive Mania Committed Suicide Committed Homicide Other: Have you been either the victim and/or perpetrator of sexual abuse? Are you currently experiencing any legal difficulties? Yes No If yes, please explain: Are you currently experiencing any job difficulties? Yes No If yes, please explain: Do you smoke? Yes No If yes, how much per day? Do you wish to quit? Yes No 5

6 How much caffeine do you consume daily? How much alcohol do you consume? Daily? Weekly? Last use of alcohol? What street drugs do you, or have you used? Last use of street drugs? Have you ever thought that you should cut down on your drinking and or drug use? Yes No In the past year, have you ever had people annoy you by complaining about your drinking or drug use? Yes No In the past year, have you ever used alcohol or street drugs first thing in the morning to steady your nerves or get rid of a hangover, or to get your day started? Yes No Have you ever been charged with a DUI or DWI? Yes No If yes, please list date(s): Month/Year Month/Year Month/Year Month/Year List all inpatient and outpatient chemical dependency treatments List all inpatient and outpatient mental health treatments Patient Signature: 6