Name: Date: Who referred you? Current Psychiatrist: Clinical Information:
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1 LIFE HISTORY QUESTIONNAIRE Adult The purpose of this questionnaire is to obtain an understanding of your life experience and background. Then we can begin to develop a comprehensive treatment program suited to your specific needs. Please complete this fully and bring to your first appointment. Name: Date: DOB: Age: Place of Birth: Significant relationship status (check one) single engaged married separated divorced remarried widowed committed relationship Who referred you? Current Psychiatrist: Clinical Information: State in your own words the nature of your main problem(s) and how long they have been present What do you expect to accomplish from therapy, and how long do you expect therapy to last? On the scale below please check the severity of your problem(s) mildly upsetting moderately severe very severe extremely severe incapacitating Previous therapy or psychiatric hospitalization(s)? Please explain. Underline any of the following that apply to you: headaches dizziness fainting spells palpitations stomach trouble anxiety easily agitated decreased energy no/more appetite anger always tired insomnia nightmares feel panicky lonely feel tense helplessness tremors/shaking depressed suicidal ideas feel guilty unable to relax sexual problems racing thoughts overly ambitious shy with people can t make friends inferiority feelings decisions tough can t keep a job memory problems perfectionistic excessive sweating poor concentration Please list additional problems or difficulties here. 1
2 Circle any of the following words which apply to you: List your three main fears: Pt Name: Worthless, useless, a nobody, life is empty Inadequate, stupid, incompetent, naive, can t do anything right Evil, morally wrong, horrible thoughts, hostile, full of hate Anxious, agitated, cowardly, unassertive, panicky, aggressive Ugly, deformed, unattractive, repulsive Depressed, lonely, unloved, misunderstood, bored, restless Confused, unconfident, in conflict, full of regrets Worthless, sympathetic, intelligent, attractive, confident, considerate Recount any fearful or distressing experiences (emotional/physical/sexual abuse, neglect)? List any situations which make you feel calm or relaxed? Have you ever lost control (e.g. temper or crying or aggressions)? If so, please describe. Have you in the past or are you presently having any suicidal ideations/ attempts? Please explain. Do you drink alcohol? If yes, how often and how much? Have you ever used illicit drugs? If so, what drug(s). Include prescription drugs if used other than prescribed. Age that you first used each drug. Do you smoke? No If yes, how much a day? Do you drink caffeine (coffee, tea, sodas) No If yes, how much a day? Who is your Primary Care or Family Physician? 2
3 Are you taking any medications? If yes, what, how much and for what condition (include over the counter medications. Do you have any allergies? / to medications? Do you have any current medical problems? Does any member of your family suffer from alcoholism, substance abuse, or anything which can be considered a mental disorder such as depression or anxiety? Happy childhood Personal Data Unhappy childhood- Explain. Health during childhood/adolescence? Any hospitalizations? (List illnesses) Father: Living or deceased? If alive, father s present age? Occupation? Health? Mother: Living or deceased? If alive, mother s present age? Occupation? Health? Siblings: Number of brothers: Brother s ages: Number of sisters: Sister s ages: Relationship with brothers and sisters> Did your parents divorce and if so what was your age when this happened? If so, did either remarry and how did this effect you? 3
4 Give a description of your father s personality and his attitude toward you: Pt Name: Give a description of your mother s personality and her attitude toward you: In what ways were you punished by your parents as a child? Were you ever bullied or severely teased? If yes, about what? Give an impression of your home atmosphere (i.e. the home in which you grew up, including compatibility between parents and between parents and children). Basically, did you feel loved and respected by your parents? Please share education including highest degree obtained. Occupation & Employer: Does your present work satisfy you? (If not, in what ways are you dissatisfied?) Ambitions/Goals: Do you have any financial concerns? With whom are you now living? (list people and relation to you) Who are the most important people in your life? 4
5 Pt Name: Present interest, hobbies or activities: What is your religion and/or spirituality? In childhood and presently: Have you ever been arrested? If yes, when and what for. Are you or were you ever in the military? Branch and service period: Are you currently in a relationship and for how long? Relationship / Marital History: How are you getting along with your partner/spouse? If married or in a relationship, partner s name, age, occupation? How many times have you been married and for how long? Describe the personality of your current spouse/partner. How many children do you have? Please list their gender and age(s) Do any of your children present specific problems? Do you have any step children and if so please list age and gender. Any history of miscarriage, abortions or infertility? (If yes please list dates) 5
6 Pt Name: Self-Description (Please complete the following): A. The most important thing that happened in my life was B. All my life I wanted C. Ever since I was a child, I D. One of the things I feel proud of is E. It s hard for me to admit F. One of the things I can t forgive is G. One of the things I feel guilty about is H. If I didn t have to worry about my image I. One of the ways people hurt me is J. My mother was always K. What I needed from mother and didn t get was L. My father was always M. What I wanted from father and didn t get was N. One of the things I m angry about is O. Which three words best describe you? Signature: Date: 6
7 7
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Driftwood Psychological Services 664 Scranton Rd., Suite 201 Brunswick, GA Phone:
1 Driftwood Psychological Services 664 Scranton Rd., Suite 201 Brunswick, GA 31525 Phone: 912-230-2436 drtara@driftwoodpsych.com Client name Date ADULT HISTORY FORM Presenting problems Why I came for counseling:
GENERAL BEHAVIOR INVENTORY Self-Report Version Never or Sometimes Often Very Often
GENERAL BEHAVIOR INVENTORY Self-Report Version Here are some questions about behaviors that occur in the general population. Think about how often they occur for you. Using the scale below, select the
Psychiatry. Name: address: Best phone number to reach you: Best times to reach you: Who referred you to the clinic today?
Email address: Best phone number to reach you: Best times to reach you: Who referred you to the clinic today? What is your reason(s) for seeking help at this time? How long have you felt this way? Have
*Please complete this form and bring to your first appointment. This information is fundamental to the assessment and treatment process.
*Please complete this form and bring to your first appointment. This information is fundamental to the assessment and treatment process. PATIENT CONTACT INFORMATION Name Age Date of birth Phone ( ) Mailing
Heron Ridge Associates, PLC PARTNER RELATIONAL PERSONAL HISTORY INFORMATION. Client s Last Name First Name M.I. Street Address Date of Birth Age
Case #: Readmit? Yes No Heron Ridge Associates, PLC PARTNER RELATIONAL PERSONAL HISTORY INFORMATION PLEASE PRINT CLEARLY Today s Date: Client s Last Name First Name M.I. Street Address Date of Birth Age
5975 Parkway North Blvd., Suite D 3060 Royal Blvd. South, Suite 110 Cumming, GA Alpharetta, GA 30022
1 5975 Parkway North Blvd., Suite D 3060 Royal Blvd. South, Suite 110 Cumming, GA 30040 Alpharetta, GA 30022 (p) 404-388-3909 www.focusforwardcc.com (f) 678-712-1945 info@focusforwardcc.com ADULT HISTORY
Address: City/State/Zip: Home Phone: Cell: Pager: Work Phone: Employer/School: Emergency Contact: Phone:
Rock Landing Psychological Group Adult Client Information Please Print Name: Relationship Status: Single Married Domestic Partner Separated Divorced Widowed Date of Birth: Female Male Ethnicity: Address:
Problem Summary. * 1. Name
Problem Summary This questionnaire is an important part of providing you with the best health care possible. Your answers will help in understanding problems that you may have. Please answer every question
PHARMACY INFORMATION:
Patient Name: Date of Birth: Referred by: Reason for Visit: Current psychiatric medications and doses: PHARMACY INFORMATION: Name of Pharmacy: Phone Number: Fax Number: Address: PRIMARY CARE PHYSICIAN
THIBODAUX REGIONAL SLEEP DISORDERS CENTER 604 N ACADIA ROAD, Suite 210 THIBODAUX, LA 70301
Name:_ Date: Address: Phone (home): Work: Marital Status: Date of Birth: Height: Weight: In case of emergency contact: ************************************************************************ Social Security#:
MERCY HOUSE RESIDENT APPLICATION FORM
MERCY HOUSE RESIDENT APPLICATION FORM PERSONAL INFORMATION Name: Date: Date of Birth: Age: Address: Email: Phone #: (Cell) (Alternitive) Marital status (please circle): Single Engaged Married Separated
Nathan Driskell, MA, LPC, NCC
Nathan Driskell, MA, LPC, NCC https://nathandriskell.com New Client Questionnaire/Psychosocial History (To be completed by the client) Please complete this form to the extent that you feel comfortable.
CERTIFICATION AND AUTHORIZATION (if applicable)
10301 Democracy Lane Suite 201 Fairfax, VA 22030 Phone: 703-547-3509 Fax: 703-383-3887 www.rrpsychgroup.com Date: PERSONAL DATA please mark with an asterisk (*) your preferred mode of contact Client Name: