Name: Date: Gender: Family and Social. Family Constellation

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Marshall Howard
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1 Name: Date: Gender: Age: Date of Birth: Race: Family and Social Family Constellation First Name Or Initials Parents (indicate biological or other): Age Gender Marital Status Occupation Education If deceased, note date, age & cause Siblings (indicate biological, half, step, adopted, etc): *If any relatives are step, half, or adoptive, please indicate and note the date they joined the family. If more space is needed, please continue on reverse. Did your parents separate at any point? How old were you during the period(s)? If parents separated, please indication reasons: What kind of relationship did your parents have when you were a child? 1

2 Did you ever witness or become aware of any emotional, physical, or sexual abuse within your childhood household? Was CPS ever involved? If so, for how long and in what capacity? Describe anything you consider noteworthy about your father & his extended family. Please include family psychological difficulties & medical problems; as well as his strengths and accomplishments. Describe anything you consider noteworthy about your mother & her extended family. Please include family psychological difficulties & medical problems; as well as her strengths and accomplishments. Describe anything you consider noteworthy about your siblings. Please include any psychological difficulties & medical problems, as well as their strengths and accomplishments. Write a few lines about the relationship with your father. Include at least 3 adjectives (descriptors). Write a few lines about the relationship with your mother. Include at least 3 adjectives (descriptors). Tell me about a sibling with whom you have a very close or conflictual relationship? Tell me about your relationship with them. Significant Romantic & Sexual History - List current or most recent 1 st First Name Or Initials Current Age Gender Highest Commitment Level (dated, engaged, married, etc.) Duration & Dates Rank the levels below from 1 to 5. Support 1=Never Supportive, Supportive Stability 1=Always Chaotic, Stable Availability 1=Never Available, Available Please describe reason for termination. 2

3 If more space is needed, please continue on reverse. What is your sexual orientation? Describe your current or most recent partner. Please include any psychological difficulties & medical problems, their strengths and accomplishments, and say a few lines about your relationship. Significant Non-Romantic Relationships (Friendships) First Name Or Initials Current Age Gender Duration & Dates Rank the levels below from 1 to 5. Support 1=Never Supportive, Supportive Stability 1=Always Chaotic, Stable Availability 1=Never Available, Available What do you like best about this person? Please describe reasons for termination. Describe your closest friend. Please include psychological difficulties & medical problems, strengths and accomplishments, and say a few words about what the relationship is like. Children First Name Or Initials Current Age Gender Nature of Relationship (Biological, Step, Adoptive) Child s Biological Father/Mother Please write anything noteworthy about your relationship with the child. 3

4 Employment Employment History Place of Employment Job Title/Role Dates of Employment Reason for Leaving Education Have you ever been diagnosed with a learning disorder? Please be specific. In school, did you receive any assistance for these difficulties, such as special education? Yes / No What services did you receive (i.e., special education, resource room, tutoring), for what subjects? Did you ever fail or repeat a class or grade level? Which ones? What were the reasons? What was your highest grade level or degree completed? If you left school early, why? 4

5 What were your relationships like with your classmates and teachers? Any problems? Psychological / Emotional Please list in order of significance any current psychological or emotional symptoms: When did these symptoms begin for you and how consistent have they been (Rank 1-5, 1 = very inconsistent, 5 = very consistent)? What do you feel are some of the contributions or causes to these issues? What do you feel would improve these issues? Have you ever received psychological/psychiatric treatment or therapy? If so, when and where? What was most helpful about these therapies? What didn t work? Suicidal Thoughts or Behavior History Approximate date and duration Thoughts (What was the content) Details of the Plan Preparation (i.e., stocking pilling medication) Attempt (i.e., overdosing on medication) Medical action required Aggression/ViolenceThoughts or Behavior History 5

6 Trauma or Abuse/Neglect Nature of traumatic event(s) (i.e., physical, emotional, sexual, combat, natural disaster) Age first experienced Approximate date and duration Perpetrator of abuse type of relationship (relative, stranger, etc) (can be self towards others as well as others towards self) If more space is needed, please continue on reverse. Medical/Neurological Please list in order of significance current medical symptoms you are experiencing When did these symptoms begin for you and how consistent have they been (Rank 1-5, 1= very inconsistent, 5= very consistent)? Have you received treatment for these symptoms? If so, when and where? Please list all current medications. Do they work? Any side effects? Please list all previous major medical/surgical procedures 6

7 Have you had a head MRI or CT scan? When/why/what were findings? Have you had a seizure? When was first/last? Type? Have you ever hit your head so hard you were knocked out? Were you ever diagnosed with a concussion? How long did you have symptoms(headaches, poor attention or memory, irritability, sensitivity to light or noise for? Which symptoms? What was the last thing you remember before you lost consciousness? What/when was your first memory after you woke up? Legal Legal History Have you ever been arrested? Nature of the violation Age at time of incarceration Duration of incarceration Current pending legal matters Religion & Spirituality What is your religious preference? How significant is spirituality in your life (Rank 1-5, 1=not significant, 5= more significant than anything) Describe anything you consider noteworthy about your religion or spirituality. Other Is there anything else that you think it would be important for me to know? 7

8 Substance (Circle where applicable) Caffeine Soda, pills Age of 1 st Use How Used? Average Amount Used Amount used during heaviest use, and duration Were you treated? Inpatient or outpatient? What problems did it cause (family, legal, work, etc)? When Last Used? How much used in last 30 days? Nicotine cigarettes, cigars, pipes, chewing tobacco Alcohol beer, wine, liquor, Hard Lemonade Marijuana/Hashish grass, pot, herb, blunts: ever mixed with PCP, Embalm? Hallucinogens acid/lsd, mushrooms, PCP, angel dust Cocaine crack, blow, rock, speedball (mixed?) Inhalants glue, Whippits, glade, solvents, nitrous oxide Stimulants speed, crank, meth, ice, amphetamines Prescription Drugs Ritalin, Dexadrine, Adderrall, Oxycontin Tranquilizers Valium, Ativan, Klonopin, Zanax, sleeping aids Opiates Pain pills, heroin, morphine, opium Steroids Other Drugs Ecstasy, GHB, Special K, DXM Robitussin, Corricidin Injected Drugs Miscellaneous Over-the-counter drugs, Tylenol PM, Benadryl 8

PATIENT IDENTIFICATION: Name: First Appointment Date: Birth Date: Address: City State Zip Home Phone #: Work #: Cell #: REFERRAL SOURCE: Referred By:

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