Choice Counseling Associates

Transcription

1 Amy Vitacolonna, MS, LMHCA, RT/CT 719 Sleater-Kinney Rd SE, Suite 212 Lacey, WA (360) (office) (360) (fax) ChoiceCounselingAssociates.com Choice Counseling Associates Intake Form - Please Print Date: Phone: : Age: Date of Birth: Address: Middle Initial: Place of employment: Presenting problem or Current Loss Describe the main problem that brought you here today: Have there been any recent deaths in family or close friends: Relationship to you: Date of Death: Briefly explain the circumstances of the death: Type of relationship with the deceased: Very close Close Not very close Distant Estranged The death was: Sudden Anticipated Amount of preparation: Were you present at the time of death? No Yes Reactions: Did you have? (check all that apply) Visitation Funeral Service/Mass Memorial Cremation

2 Current Symptom Check list (check all that apply and rate the intensity of each symptom checked) None = Symptoms not present at this time Mild = Impacts quality of life, but no significant impairment of day-to day functioning Moderate = Significant impact on quality of life and/or day to day functioning Severe = Profound impact on quality of life and/or day to day functioning Symptom None Mild Moderate Severe Note Depressed Mood Appetite Changes Sleeping changes Feelings of Guilt Fatigue/low energy Poor Concentration Irritability/Anger Substance Abuse Anxiety Hopelessness Physical Complaints Social Isolation Worthlessness Loss of Pleasure or interest in hobbies Weight loss Weight gain Intense Crying Recurring thoughts/images Feelings of Panic Loneliness Memory impairments Disorganized thoughts Family Information: Mother s Father s Spouse s 1 st Child s 2 nd Child s 3 rd Child s 4 th Child s Significant Others (brothers, sisters, friends, etc.) Please specify relationship Relationship

3 Relationship Relationship Relationship Relationship Type of relationships: Very Close Close Casual Not Close Distant Estranged Present Marital Status : Never married Engaged Widowed Separated Divorced Divorced and remarried Widowed and remarried Married Number of marriages: Other (specify): Is there a history of child abuse? Yes No If so, when did this abuse occur? Date If so, which type? Physical Emotional Verbal Sexual Neglect If so, the abuse was as a: Victim Perpetrator Who victimized you? Any current or history of being a sexual predator? No Current Past history Social Relationships Check how you generally get along with other people: (Check all that apply) Affectionate Aggressive Avoidant Friendly Leader Outgoing Follower Submissive Fight/argue often Shy/withdrawn Other Describe your support system: Very Close Close Casual Not Close Distant Estranged My support system is Adequate? No Yes Cultural/Ethnic To which Cultural or Ethnic Group do you belong? Caucasian African-American/Black Asian Native American Middle Eastern Hispanic Cuban Mexican Puerto Rican Spanish Culture of Origin South or Central American Other (specify): Any cultural/ethnic information that would be helpful for your counselor to know/understand? (describe below) Spiritual/Religious How important is your spiritual/religious beliefs? Very important Somewhat important Not important Not spiritual/religious at all

4 Are you affiliated with a spiritual/religious group? Yes No If so, what? If so, do you regularly participate with this group? Yes No If so, how often? Were you raised within a spiritual or religious group? Yes No If so, what? Are their any spiritual/religious issues that are bother you that you would like to discuss? (describe below) What role does faith/prayer have in your everyday life? How has your faith been a part or affected by this situation? Legal Are you currently 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 currently on probation or parole? Yes No Past: Have you had ( all that apply) Criminal Involvement DWI, DUI, etc: Civil Involvement If you checked any of the above, please fill in the following information. Charges Date Where (city) Results Education Fill in all that apply Are you currently enrolled in school? Yes No High School Graduate When? Graduated? Yes No GED? Yes No College When? Graduated? Yes No Degree: Graduate When? Graduated? Yes No Degree: Post Graduate When? Graduated? Yes No Degree: Other training:

5 Special Circumstances (e.g. Learning Disabilities, gifted): Yes No Explain: Employment Currently: Full-time Part-time Temporary Retired Laid-off Disabled Student Other: Employer Dates Title Reason you left the job Military Military experience? Yes No Combat experience? Yes No If so, where? Branch of Military: Army Navy Air Force Marines Coast Guard Date of Discharge: Years of Service: Type of Discharge: Rank at Discharge: Medical Health Describe your health status: Excellent Good Fair Poor List any health issues you have (i.e. high blood pressure, diabetic, etc): List any prescription drugs you are currently taking: Drug s name Dosage (mg/daily) Dates taken Purpose

6 Primary Care Physician Information: Doctor s : Address City Zip Code Phone Number Date of last Visit: Date of last Physical: Date of last Surgery: Reason: Results: Reason: Upcoming Surgery: No Yes When? Reason: Check if you have noticed any of the following changes: Physical Activity Levels Sleeping patterns Eating Patterns Mood Behavior Weight Energy Level Enjoyment of pleasure activities Other: Describe the changes you checked: Are you currently taking illegal drugs? No Yes If so, what? If so, how long have you used this drug? Frequency of use? How much? Are you drinking Alcohol? No Yes Frequency of use? If so, how long have you used alcohol? How much? Describe when and where you typically uses these substances: Describe any changes in your use patterns: Describe how your use has affected your family or friends (what are their perceptions of your use): Have you ever wanted to stop but feel you cannot? No Yes Counseling/Mental Health Have you ever received counseling before? No Yes If so, why? Have you ever been diagnosed with a mental disorder? No Yes If so, what was that diagnosis (specify):

7 With whom? When? Have you ever been hospitalized for psychological reasons? No Yes If so, explain. Have you ever had past thoughts of seriously hurting or killing yourself? No Yes If so, explain. Have you ever had a suicide attempt? No Yes If so, explain. How have you coped with pervious life pains and/or troubles? List your personal Strengths: What are the issues that you would like to work on in counseling? What are your Goals for Counseling? Concurrent stressors/crisis (check all that apply) Divorce/Separation Date: Limited Finances Date:

8 Illness/injury Date: Other recent deaths Date: New home or job Date: Other Date: Are you currently thinking about hurting or killing yourself? No Yes If so, how? Do you have the means to carry it out? No Yes How satisfied are you with your life these days? (circle one) Not at all Somewhat satisfied Very Satisfied Rate the intensity of your emotional pain today? (Circle 1) No pain at all Extreme Pain/intolerable Are you currently seeing another counselor and/or Psychiatrist or Psychologist? No Yes If yes, who? A counselor A Psychiatrist A Psychologist Address City Zip Phone Anything else you would like your counselor to know: Signature Date