MN Couple Therapy Center 1611 County Road B, Suite 204 Roseville, MN
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- Lenard Lee Douglas
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1 MN Couple Therapy Center 1611 County Road B, Suite 204 Roseville, MN FULL NAME DATE DOB Presenting Problem 1. What is/are the reason(s) you are seeking therapy today? 2. Did a specific event lead to this request for service? If yes, please describe the incident. 3. Please describe what you hope to accomplish in this therapy or what you hope will be different in your life as a result of attending therapy. 4. How long has the problem been present? 5. What solutions to the problem have you tried, and what were the results? 6. How much does this problem affect your life? (Please circle the number that best applies) Not at all A Little bit A lot All the time 1. Personally Family life Socially Work Health How were you referred to this service? (Please circle) Self Spouse/Other Physician Employer Court Other (Please specify): 8. Do you make use of any community-based support groups (e.g. 12-Step Programs, social support groups, etc)? If yes, please specify: 9. Do you have an involvement with any of the following people or services? County Social Worker Probation Officer Adult/Child Protection Guardian Ad Litum Worker s Compensation If so, please describe.
2 Symptoms 10. Please look these items over and circle the number that best describes how these symptoms have bothered you in the past two weeks. During the past TWO (2) WEEKS, how much (or how often) have you been bothered by the following problems? None Not at all Slight Rare, less than a day or two Mild Several days Moderate More than half the days I. 1. Little interest or pleasure in doing things? 2. Feeling down, depressed, or hopeless? II. 3. Feeling more irritated, grouchy, or angry than usual? III. 4. Sleeping less than usual, but still have a lot of energy? 5. Starting lots more projects than usual or doing more risky things than usual? IV. 6. Feeling nervous, anxious, frightened, worried, or on edge? 7. Feeling panic or being frightened? 8. Avoiding situations that make you anxious? V. 9. Unexplained aches and pains (e.g., head, back, joints, abdomen, legs)? 10. Feeling that your illnesses are not being taken seriously enough? VI. 11a. Thoughts of actually hurting yourself? 11b. Suicidal thoughts, plans, or attempts Have you ever thought about, planned or attempted suicide? Thought about o YES o NO Planned o YES o NO Attempted o YES o NO If yes to any of these, when was this? VII. 12. Hearing things other people couldn t hear, such as voices even when no one was around? VIII. IX. 13. Feeling that someone could hear your thoughts, or that you could hear what another person was thinking? 14. Problems with sleep that affected your sleep quality over all? 15. Problems with memory (e.g., learning new information) or with location (e.g., finding your way home)? X. 16. Unpleasant thoughts, urges, or images that repeatedly enter your mind? 17. Feeling driven to perform certain behaviors or mental acts over and over again? XI. 18. Feeling detached or distant from yourself, your body, your physical surroundings, or your memories? XII. XIII. 19. Not knowing who you really are or what you want out of life? 20. Not feeling close to other people or enjoying your relationships with them? 21. Drinking at least 4 drinks of any kind of alcohol in a single day? 22. Smoking any cigarettes, a cigar, or pipe, or using snuff or chewing tobacco? 23. Using any of the following medicines ON YOUR OWN, that is, without a doctor s prescription, in greater amounts or longer than prescribed [e.g., painkillers (like Vicodin), stimulants (like Ritalin or Adderall), sedatives or tranquilizers (like sleeping pills or Valium), or drugs like marijuana, cocaine or crack, club drugs (like ecstasy), hallucinogens (like LSD), heroin, inhalants or solvents (like glue), or methamphetamine (like speed)]? Copyright 2013 American Psychiatric Association. All Rights Reserved. (Edited By MN Couple Therapy Center) Severe Nearly every day Highest Domain Score (clinician)
3 Contributing Factors 11. Which of the following do you think contribute to your problem(s)? (Check all that apply) Family move to a new home Death of a family member Developmental problems Adjustment to sitter/day care Birth of child or sibling Suspect physical/sexual abuse Parental quarreling/arguing Adjustment to school Known physical/sexual abuse Post-divorce adjustment School problems Law violations Financial stress Absenting home or school Dishonesty Marital unfaithfulness Separation of parents Remarriage of parent Parenting problems Spiritual problems Negative peer influence Medical problems Drugs or alcohol use Career change Previous therapy Work problems Violence Anger Empty nest Other: Medical and Mental Health History 12. Who is your primary care physician and your primary clinic? 13. Who else do you regularly see as part of your routine health care? 14. List any significant health problems, past or present, including surgeries and/or illnesses with the corresponding dates. 15. Are you currently taking any medications? No Medication Dose and number of pills you take per day (e.g..25 mg. 3 times per day) Prescribing doctor 16. Have you ever taken any other medications for depression, anxiety, or mental health issues? No If yes, please list: Medication Name Prescribed for? (eg: depression, anxiety) When (approx) How long were you on the medication? Prescribing doctor
4 17. List other therapy or counseling you have received in the past or are receiving now: Therapist s name Location Approximate dates 18. What has been helpful in the past in therapy What has not been helpful 19. If you think it would be helpful for your therapist to contact a previous therapist or physician, you will need to sign a Release of Information form. 20. Have you ever been hospitalized for mental health reasons? Substance Use 21. Please describe your use of the following substances: Daily Weekly Occasionally In the past but not now Not at all Caffeine Tobacco Alcohol Prescription drugs Inhalants Street drugs Over-the-counter medications Other: 22. Have you ever had treatment for any type of alcohol or substance use?
5 Resources 23. What has helped you manage or endure your current problem? 24. Who are the people in your life that currently play a supportive, influential, or friendship role? 25. What interests or passions give meaning to your life? 26. Do you have any spiritual beliefs or practices that are important to you? 27. What aspects of your culture, heritage, or ethnicity would you like your therapist to be aware of? Family Information 28. Please list those who you consider part of your immediate family and/or your current household. Name Age Relation to you Living with you? Other 29. Is there anything else that you would like your therapist to know that you have not written about on any of these forms? Signature and Date I acknowledge that the information on this form is accurate to the best of my knowledge, and that I will inform my counselor of any changes in my personal information. Client Signature Date
Part I. Demographics. Part II. Presenting Problem. Who referred you to WellStar Psychological Services?
Part I. Demographics Today s Date Current Time : Patient s Name (Last) (First) (MI) Patient s Date of Birth Patient s Gender Female Male Patient s Address Primary Phone Ok to leave a message? Email Address
Neurobiopsychosocial History
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37 South 2 nd East, Rexburg, ID 83440 208.356.0234 Patient Information Name: Date: Address: City: State: Zip Code: Telephone: Home: Cell: Birth date: Social Security Number: - - Marital Status: Married
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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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