Sonja Benson, Ph.D., PLLC Licensed Psychologist
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1 Sonja Benson, Ph.D., PLLC Licensed Psychologist Date_ Referred by Name Date of Birth Social Security # Address_ City State Zip code Daytime Phone Nighttime Phone Cell Phone Male( ) Female ( ) Ethnicity Age Occupation Marital Status Spouse s Name if married Emergency Contact Person/Relationship Phone/Address for Emergency Contact: Name Family Information People Currently Living in your Household Relationship Age Birthplace Occupation or Grade Level
2 Name Original Family Members (parents, siblings, etc) Relationship Age Where Living Occupation or Grade Level Do you have any children not living with you? If yes, please list their names, ages, and where living: Has any member of your family been hospitalized for mental health concerns? If yes, please list who, when and for what reason: Do/did you have any family members who have/had problems with drinking alcohol or using drugs? If yes, please list who, when and if it is still a problem: Has any member of your family killed themselves or tried to kill themselves? If yes, please list who, when, and what happened: What is your worst memory about your family when growing up? _
3 What is your best memory about your family when growing up? If you could change anything about your family situation right now, what would it be? Health/Mental Health Information Have you ever seen a counselor, psychologist, psychiatrist or other mental health professional for any mental health or drug/alcohol concerns? If yes, please list who, when, and why: Have you ever been hospitalized for mental health or drug/alcohol concerns? If yes, please list when and for what reason: Do you have thoughts of killing yourself? If yes, how often does this happen? Have you ever tried to kill yourself? If yes, when was this? Did you receive medical help? Please check any of the following areas that you have experienced: ( ) Head Injury ( ) Loss of Consciousness ( ) Seizures ( ) Convulsions If yes, please explain: Current Medications (Please include prescription, over the counter, herbs, vitamins, and other remedies) Medication Dosage and When Taken Reason for Taking
4 Past Medications (Particularly those taken for Mental Health Concerns) Medication Dosage and When Taken Reason for Taking Have you ever had surgery? If yes, please list when, where, why and type of surgery _ Height Weight Has your weight gone up or down by more than a few pounds in the past 3 months? If yes, how much? Are you satisfied with your weight? Please list any current health concerns: Please list past serious illnesses and health concerns: Exercise and Physical Recreational Activity Type of Activity How often Would you describe yourself as physically active? Are you more or less active than 3 mos ago? 6 mos ago?
5 Use of Substances (on Average) Current Amount Most Used in the Past Alcohol glasses per day or glasses per week glasses per day or glasses per week Tobacco cigarettes per day cigarettes per day Caffeine (tea, coffee, servings per day servings per day soda) Marijuana per day or per week per day or per week Cocaine Diet Pills pills/doses per day or pills/doses per day or Laxatives Stimulants Painkillers Other pills/doses per day or doses per day or doses per week Amount: pills/doses per day or doses per day or doses per week Amount: What if any relationships do you have that are not going well at this time? What if any relationships do you have that are supportive and fulfilling at this time? What are your strengths?
6 Please check any symptoms that describe how you feel, think, or behave currently or during the past few weeks: ( ) Chronic sadness ( ) Low frustration tolerance ( ) Crying episodes ( ) Irritability ( ) Hopelessness ( ) Sleep problems ( ) Difficulty concentrating ( ) Memory problems ( ) Loss of appetite ( ) Thoughts of suicide ( ) Overeating ( ) Withdrawing from others ( ) Nausea/Vomiting ( ) Difficulty functioning at work ( ) Difficulty making decisions ( ) Difficulty functioning socially ( ) Low energy/fatigue ( ) Reduced interest/pleasure in activities ( ) Agitation ( ) Panic attacks ( ) Restlessness ( ) Fear of leaving home ( ) Excessive worry ( ) Avoidance of public places ( ) Fearfulness ( ) Avoidance of social situations ( ) Trembling/shaking ( ) Pounding heart/palpitations ( ) Fear of loss of control ( ) Shortness of breath ( ) Fear of dying ( ) Feeling detached from others/life ( ) Intrusive thoughts of bad memories ( ) Nightmares ( ) Flashbacks/re-living bad experiences ( ) Easily startled/upset ( ) Hear voices others do not hear ( ) Seeing things others do not see ( ) Fearful others are talking about me ( ) Fearful someone is plotting against me ( ) Difficulty completing tasks/distracted ( ) Taking on too many tasks ( ) Difficulty focusing ( ) Frequent forgetfulness ( ) Tendency to act impulsively ( ) Difficult to wait my turn ( ) Not well organized ( ) Problems with co-workers ( ) Legal Problems ( ) Problems in school growing up ( ) Difficulty at work ( ) Hard to stay with a job very long ( ) Racing thoughts ( ) Staying up for days without sleep ( ) Excessive spending ( ) Multiple sexual partners ( ) Excessive gambling ( ) Marital conflict ( ) Aggressive/abusive toward others ( ) Confused/worried about sexual behavior ( ) Tried to kill myself ( ) Thoughts of physically hurting others Please describe why you are seeking help at this time:
1811 B Green Circle Valdosta, GA Do you have any problems at this time?
TVC 1811 B Green Circle Valdosta, GA 31602 229-244-9688 Name: Date: Do you have any problems at this time? Please check any symptoms that describe how you feel, think, or behave currently or during the
ADULT HISTORY QUESTIONNAIRE
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ADULT QUESTIONNAIRE. Date of Birth: Briefly describe the history and development of this issue from onset to present.
ADULT QUESTIONNAIRE Name: Address: Preferred phone number to reach you: Is it okay to leave a message? Yes No (Please check one) Date of Birth: Reason(s) for seeking treatment at this time? Briefly describe
Client s Name: Street City State Zip. Home Phone Work Phone Cell Phone. Student: Full-time Part-time Grade School. Current or past Education:
Office of: Sarah Horvath, LCSW Self-Report Form Page 1 Client s Name: Person completing report: Relation to Client: Street City State Zip Home Phone Work Phone Cell Phone Email: Date of Birth: Age: Gender:
Do not write below this line DSM IV Code: Primary Secondary. Clinical Information
New Client Registration Today s date Name Age Sex Address Social security # Date of birth Home phone May I call you at this number? y / n Leave a message? y / n Other numbers at which I can call you Can
Client s Name: Today s Date: Partner s Name (if being seen as a couple): Address, City, State, Zip: Home phone: Work phone: Cell phone:
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Date of Assessment ADULT PSYCHOSOCIAL HISTORY/INITIAL THERAPY INTAKE FORM Identifying Information: Name: Address: Age: D.O.B: Phone Number: Race: Gender: Religious Affiliation(optional): Current Household
Please check all the behaviors and symptoms that you consider problematic:
Name Date Address Phone # Date of birth Email address Social Security Describe the issue that brought you here today: Please check all the behaviors and symptoms that you consider problematic: Distractibility
MINDFUL WELLNESS CENTER, PLLC
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problems/medications: Current supplements/vitamins/herbs: Past medical problems/medications: Other doctors/clinics seen regularly:
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