Full Circle Psychotherapy: Ayla Marie Carter, MA, LMHC
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- Clinton King
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1 Full Circle Psychotherapy: Ayla Marie Carter, MA, LMHC (253) Name (First, Middle, last): Birthdate: Age: Gender: Sexual Orientation: Race/Ethnicity: Country of Origin: Marital Status: Spouse or Partner Name: Address: Home Phone: Cell: Address: Best way to contact you: Ok to leave a message? EMERGENCY CONTACT: Name: Phone: Relationship: REFERRAL SOURCE: Name: Phone: May I contact this person regarding the referral? MEDICAL CARE PROVIDERS: Primary Care Physician: Phone: Psychiatrist or ARNP: Phone: May I contact your providers if needed for coordination of care? REASON FOR THERAPY What brings you to therapy at this time? What do you hope to achieve in therapy? What strengths do you feel you have that will support you in attaining this goal? What are ways you have managed stressors or difficult situations in the past? What are some things that you do to feel good about and take care of yourself? How would you describe the quality of your social relationships?
2 2 DEVELOPMENTAL HISTORY: Where were you born? Were there any complications related to your birth? If yes, please explain: Did you have any medical problems, illnesses, or hospitalizations during your childhood? If yes, please explain: Did your family move frequently? Is there anything else about your childhood you think I should know? EDUCATION & CAREER HISTORY: Highest degree completed? Did you like school? Did You have any learning disabilities? Current job: Employer: Length of current job CURRENT FAMILY: Please complete the following information for each member of your current family. Include information on former spouses or partners. Name Relationship Age Gender Ethnicity Relationship Quality If you are currently in a relationship, how long have you been together?
3 3 How would you describe the quality of your relationship at this time? Do you share custody of any children? If so, please describe the relationship between you and other guardian: Have you ever lost any children through: Death Miscarriages Abortions Adoptions CPS Is there any other information you think I should know about your current, or past relationships? FAMILY OF ORIGIN: Mother s name: Currently living? Yes No Father s Name: Currently living? Yes No Please describe your relationship with your Mother growing up: Please describe your relationship with your Father growing up: Did your parents divorce when you were a child? Yes No - If yes, how old were you? Who had legal custody? Were you adopted Yes No If yes, at what age; and when did you become aware of this? Were you ever in foster care? Yes No If yes, what age were you and for how long? Do you have any siblings? Yes No Name Age Gender Full Step Half Adopted Relationship Quality
4 4 MENTAL HEALTH HISTORY Have you been diagnosed with a mental illness? When What was the diagnosis? Do you agree with the diagnosis? Have you ever been hospitalized for mental health related reasons? Have you ever attempted suicide? Explain: Please describe any other inpatient, intensive outpatient, or partial hospitalization program in which you have participated in: Is there a family history of mental illness? Please describe Please circle all that currently apply, or make a check if applied in your past Anxiety Worry Panic attacks Obsessions/compulsions Phobias Depressions Self harm Suicide thoughts/attempts Grief or loss Loss of Spiritual faith Anger/irritability Legal issues Violent thoughts/behaviors Euphoria/Mania Hallucinations Traumatic experience Physical abuse Emotional/verbal abuse Sexual abuse/assault Dissociation ADD/ADHD Alcoholism/addiction Restricting food intake Binge eating Purging of food Body dissatisfaction Sleep problem Chronic pain Aging issues Sexual identity concerns Self-doubt Self-esteem Career concerns
5 5 In the past 4 weeks, how would you describe the following? Please circle all that apply MOOD Sad Depressed Tearful Anxious Numb Angry Happy Euphoric SLEEP Insomnia Trouble falling asleep Trouble staying asleep Fatigued Too much sleep Can t get out of bed ENERGY Exhausted Low Normal High Manic ABILITY TO EXPERIENCE PLEASURE No joy or pleasure Can enjoy some things Normal joy and pleasure APPETITE No appetite Less than normal Normal Greater than normal Out of control eating OUTLOOK ON LIFE Anxious Hopeless Not sure Hopeful Positive MOTIVATION None Low Normal More than usual SOCIAL-CONNECTEDNESS Isolated Withdrawn Socially anxious Lonely Feel socially supported SELF-TALK Self-Critical Angry Perfectionistic Compassionate Positive No awareness of self-talk SELF-CARE Neglectful of own needs Minimal Normal Focused on own needs
6 6 MEDICAL HISTORY Please describe any significant medical problems, past and present, including any hospitalizations or surgeries. Please provide dates Please list all medications you are currently taking Medication Name Dose Reason for Taking Date Started Please list any psychotropic medications you have taken in the past, what they were for, and why you stopped taking them SUBSTANCE USE: How many alcoholic drinks do you consume: Per day Per week How often do you use marijuana? # times: Per day Per week Are there other substances you use now, or have in the past? Has anyone ever asked, suggested, or demanded you seek substance abuse treatment? Do you have a history of DUI s? Have you ever been incarcerated? Explain:
7 7 SPIRITUAL HISTORY Were you raised in religious faith? If yes, what faith? How was that experience for you? Are you still involved with that faith? Is spirituality/religion important to you now? Do you have a faith that you currently practice? If so, what faith? Do you share this with your family/partner/children? Is there any other information we have not covered that you feel would be helpful for me to know at this time?
Life, Family and Relationship Questionnaire
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KARI KOKKO, MSW, RSW CLIENT INTAKE FORM Client Name: Please describe your main reason(s) for seeking services at this time? CURRENT RELATIONSHIP STATUS Single Common Law Separated Widowed Cohabitating
Teresa Donato Licensed Clinical Professional Counselor 512 North 29 th, Suite INTAKE FORM/DIAGNOSTIC ASSESSMENT
Teresa Donato Licensed Clinical Professional Counselor 512 North 29 th, Suite 204 406-696-2096 INTAKE FORM/DIAGNOSTIC ASSESSMENT Name: Address: Date: Telephone Numbers: Best times to call: Emergency Contact
PERSONAL HISTORY QUESTIONNAIRE
PERSONAL HISTORY QUESTIONNAIRE Here are several pages of questions that we want you to answer about yourself. Please answer them to the best of your ability, as completely and honestly as you can. Completing
PATIENT IDENTIFICATION: Name: First Appointment Date: Birth Date: Address: City State Zip Home Phone #: Work #: Cell #: REFERRAL SOURCE: Referred By:
Andrew E. Leifer, M.D., P.C. 1202 Bergen Parkway, Suite 211 Evergreen, Colorado 80439 General Adult Psychiatry Outpatient and Hospital Care Medical Consultation-Liaison Service Telephone (303) 674-6074
Heartland Wellness Counseling Health Questionnaire
Heartland Wellness Counseling Health Questionnaire Today s Date: CLIENT INFORMATION Last name: First: Middle: Initial: Nick name: Marital status: Single Married Divorced Separated Widow Social Security
PSYCHOLOGICAL EVALUTAION QUESTIONNAIRE
PSYCHOLOGICAL EVALUTAION QUESTIONNAIRE The purpose of this questionnaire is to obtain an understanding of your life experience and background which is part of the evaluation process. Please bring this
GeMS Young Adult Self-Report Questionnaire
Patient Name: D.O.B: MRN: GeMS Young Adult Self-Report Questionnaire This form will help us learn about you prior to your appointment in GeMS. It asks about your gender identity experience, mental health,
New Patient Information Form
New Patient Information Form Patient Identification Prenatal Alcohol & Drug Exposure Clinic FASD CLINIC Patient s OHIP N. Female Male Race Patient s Name Birth Date Age First Middle Last Patient s Address
Steve Barns & Associates The Counseling Center of Denton Bible Church Christian Counseling Services Individual, Marriage, & Family
: Last First MI Male Female / / Age Email: @ Home: ( ) - Cell: ( ) - Address: Street (or P.O. Box) Apt. # City State Zip Code Emergency contact: ( ) - Place of Employment: How long? yrs. mos. Current Marital
Address: Spouse/Partner Name: Phone: Address:
Adult Wellness Assessment Please take a few minutes to fill out this form. The information will be helpful in better understanding your individual needs and situation. Thank you. Personal Information Name: