PERSONAL HISTORY What are your strengths? (i.e. skills, positive qualities or characteristics) Hobbies/Extracurricular Activities (Please list): ETHNI
|
|
- Barry Chambers
- 5 years ago
- Views:
Transcription
1 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 Composition: REASONS FOR REFERRAL: Why you are you seeking services? Check symptoms described or observed and how often the symptom(s) present. Circle appropriate number : (1-Mild, 2-Moderate, 3-Severe) How Often? How Often? Anxious Poor Self- Esteem Panic Attacks Depressed Moods Repetitive Thoughts Physical Symptoms Repetitive Behaviors Poor Concentration Guilt Mood Change Fear of Leaving Home Irritability Excess Talking Sleep Disturbances Sleep Disturbances Worthlessness Poor Memory Uncomfortable Thoughts Decreased Energy Seeing/Hearing things and Interest that may not be present Significant Appetite Change Suspiciousness Weight Loss lbs Impulsiveness Weight Gain lbs Temper Problems Tearfulness Grief Other Eating Disorder Sexual Assault CURRENT CONCERNS/ NEEDS: What do you hope to receive through counseling? History of Presenting Concerns: Client Name: Clinician Name & Credentials:
2 PERSONAL HISTORY What are your strengths? (i.e. skills, positive qualities or characteristics) Hobbies/Extracurricular Activities (Please list): ETHNIC/CULTURA L/SPIRITUA L CONCERNS Raised Outside The U.S.: No Yes Where: How long have you lived in the U.S? Any cultural, ethnic, or spiritual concerns that may effect your treatment? No Yes (please list) EMPLOYM ENT HISTORY: Employer s Name (optional): Occupation: Longest continuous employment in the last ten years: MILITARY HISTORY: Yes No Branch of Service: Served From: to Type of Discharge FIREARMS REVIEW : Guns/Ammunition Maintained at Home: Security/Storage of Firearms: LEGAL: Current charges pending: Yes No Charged with: Current probation/parole: Yes No Charges: Prior Arrests/Incarcerations: Yes No Why: When: Any involvement with Children s Bureau? Yes No If Yes, Describe: Have you applied for: Supplemental Security Income Public Welfare Benefits Social Security Disability Worker s Compensation Client Name: Clinician Name & Credentials:
3 SUBSTANCES USED: Tobacco Never: Current: Past: How long ago? Substance used: Cigarettes Pipe/Cigars Chewing Tobacco Ecig/Vape Alcohol Never: Current: Past: How long ago? Substance used: Beer Wine Liquor Caffeine: Never: Current: Past: How long ago? Substance used: Coffee Tea Soda Other (list: ) Stimulants Never: Current: Past: How long ago? Type of use: Prescribed Recreational Substance used: Methamphetamine Adderall Cocaine Other (list: ) Marijuana: Never: Current: Past: How long ago? Type of use: Prescribed Recreational Opiates/Opiods: Never: Current: Past: How long ago? Type of use: Prescribed Recreational Substance used: Heroin Codeine Oxycodone Morphine Fentanyl Hydrocodone Methadone Other (list: ) Phencyclidine (PCP): Never: Current: Past: How long ago? Type of use: Recreational Sedatives: Never: Current: Past: How long ago? Type of use: Prescribed Recreational Substance used: Barbiturates Benzodiazepines Other (list: ) Client Name: Clinician Name & Credentials:
4 MEDICAL HISTORY Medication Allergies: Yes No If Yes: Medications: Reaction: Serious Medical Condition: What? When? CURRENT MEDICATIONS: (Including prescriptions and over the counter medications) Medication: Dosage: Physician: PHARMACY INFORMATION : (Please list Name, Address, and Phone Number of the pharmacy you most often use in the case medication is prescribed. Name: Address: Phone Number: PRIOR PSYCHIATRIC TREATMENT HISTORY: Describe past counseling treatment experience for yourself (when, how long, how effective): Past Psychiatric Diagnosis: Past Psychiatric Hospitalizations: PRIOR PSYCHIATRIC MEDICATIONS: Yes No Client Name: Clinician Name & Credentials:
5 If Yes: Medications: Helpful: Yes No Yes No Yes No Yes No Do you have nightmares or reoccurring dreams? If so, please describe. SUICIDAL ASSESSMENT: Thoughts: Occasional Frequent None Prior Suicide Attempts: Yes No If Yes, When? Method: Treatment: Yes No If Yes, Where: RELATIONS HIP/ MARITAL HISTORY If married: Length of Current Marriage: Date of Marriage: Quality of Marriage: Previous Marriages: Length of Marriage: Date of Marriage: Reason for Termination: Any additional comments regarding marital history: Current relationship status: Going back as far as you can remember, have there been any significant deaths/losses in you life? If so, please describe. Have you ever been in any other past significant relationships? If so, please describe. Client Name: Clinician Name & Credentials:
6 If you have children, please describe your partner s parenting style. What traits about your partner initially attracted you to him/her? What are some hopes for your current relationship with your partner? Have you ever had a miscarriage or been in a relationship when there was a miscarriage? If so, what effect did this have on you? Have you ever had an abortion or been in a relationship where the was one? If so, what effect did this have on you? ABUSE HISTORY: Have you ever been abused: Physically Yes No Emotionally Yes No Sexually Yes No If yes, please describe: Going back as far as you can remember, have there been any times that you have been kicked, hit, slapped, or otherwise physically hurt? If so, please describe. Going back as far as you can remember, has anyone significantly older to you made any kind of sexual adv ances to you? If so, please describe. Client Name: Clinician Name & Credentials:
7 Have you ever been raped? Please describe (when did this occur, effect on you, etc.) Have you ever been forced into any sexual relationship that you were not comfortable with? FAMILY HISTORY: (List people who live in your home and their relationship to you.) Any family member (s) who have emotional/psychiatric problems: Yes No If Yes, please list: Family Member: Type of Problem: Treatment: Yes No Yes No Yes No Yes No Yes No Yes No Describe history of alcohol, substance abuse issues and/or problems with prescription medications with yourself and/or family of origin members. Are your parents alive or deceased? If alive, do they live in close proximity to you and how often do you have contact with them? Describe your present and/or past relationship with Mother, Father, Step- Mother, Other Parent Figure. Describe your parent s style of parenting when you were growing up? Client Name: Clinician Name & Credentials:
8 Do you have siblings? If so, how many? Describe your relationships with your siblings/how often do you have contact with them? Is there anything I didn t ask that has had a signifigant impact on your life? Please add any signifigant information about yourself, or your situation, that would be helpful to us to know, as your plan of treatment is developed: What do you believe would be most helpful for your treatment: Do you have a Advanced Mental Health Directive? Yes or If yes, please supply a copy for your file. No Emergency Contact Information 1. Name: Address: Phone: 2. Name: Address: Phone: Client Name: Clinician Name & Credentials:
9 THERAPIST USE PCP Notified: Yes No Refused Primary Care Physician: Phone #: Address: How long have they been a patient? Client Rights Provided: Yes No CLINICIAN S IMPRESSIONS/S UMMARY: PROVISIONAL DIAGNOS IS: AXIS I: AXIS II: AXIS III: AXIS IV: AXIS V: Current GAF: Highest In The Past Year: Intake Clinician s Signature: Credentials: Date: Client Name: Clinician Name & Credentials:
New Client Information. address: Date of Birth:
Milwaukee Area Psychological Services, S.C. (MAPS) 401 E. Kilbourn Avenue, Suite 402 Milwaukee, WI 52302 414-269-8660 (phone) 414-269-8656 (fax) New Client Information Your responses to the following questions
More informationproblems/medications: Current supplements/vitamins/herbs: Past medical problems/medications: Other doctors/clinics seen regularly:
Main Purpose of the consultation (Please give a brief summary of the main problems) What happened to make you seek evaluation at this time? MEDICAL HISTORY Current medical Prior Attempts to correct the
More informationClient 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:
More informationPATIENT 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
More informationName: Gender: male female Age: Date of birth: / / Preferred phone: cell home work other. Alternate phone: cell home work other.
Casey Alexander Paleos, MD NEW CLIENT INTAKE FORM 775 Park Avenue, Suite 200-2 Huntington, NY 11743 tel 631-629-5887 Date: / / BASIC INFORMATION Name: Gender: male female Age: Date of birth: / / Preferred
More informationElana Klemm, LPC, NCC Compassionate Care Counseling 4343 Shallowford Rd. Suite H-1B Marietta, GA ( ) NEW CLIENT INFORMATION
Elana Klemm, LPC, NCC Compassionate Care Counseling 4343 Shallowford Rd. Suite H-1B Marietta, GA. 30062 (404 783-7086) NEW CLIENT INFORMATION Last Name of Client First Name Middle Initial Social Security
More informationIntake Form. Presenting Problems and Concerns. When did it start and how does it affect you:
Intake Form Name: Date: Presenting Problems and Concerns Describe the problem that brought you here today: When did it start and how does it affect you: Estimate the severity of the above problem: Mild
More informationADULT PATIENT HISTORY FORM. Name: Address: City: State: Zip: Occupation (if applicable): Religious Affiliation (if applicable):
ADULT PATIENT HISTORY FORM DEMOGRAPHIC INFORMATION: Name: Address: City: State: Zip: Age: Date of Birth: Gender: Male Female Transgender Marital Status: Never Married Domestic Partners Married Separated
More informationPSYCHIATRIC INTAKE AND TREATMENT PLAN-PART I TO BE FILLED BY PATIENT PLEASE PRINT
DOB: / / / PSYCHIATRIC INTAKE AND TREATMENT PLAN-PART I TO BE FILLED BY PATIENT PLEASE PRINT Date Age Gender M F Current address: Married. Single Separated Divorced Widowed If patient is a child, he/she
More informationSonja Benson, Ph.D., PLLC Licensed Psychologist
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 Email Male( ) Female ( ) Ethnicity
More informationCLIENT INFORMATION FORM. Name: Date: Address: Gender: City: State: Zip: Date of Birth: Social Security Number:
Name: Address: Gender: City: State: Zip: Date of Birth: Social Security Number: Contact Telephone Numbers Please complete relevant information and indicate the number at which you wish to be contacted
More information1811 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
More informationClient s Name: Today s Date: Partner s Name (if being seen as a couple): Address, City, State, Zip: Home phone: Work phone: Cell phone:
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: Private email address: Student? If yes, where and major? May we leave
More informationIntake Questionnaire For New Adult Patients
Intake Questionnaire For New Adult Patients This brief questionnaire will help me get to know you better in order to provide the best possible care for you. Please answer as honestly and completely as
More informationPatient Questionnaire. Name: Date: A. What are the main concerns or problems that brought you here today?
Patient Questionnaire Name: Date: D.O.B.: Age: Referred By: Presenting Problem A. What are the main concerns or problems that brought you here today? B. Problem Checklist: please circle all that apply:
More informationMN Couple Therapy Center 1611 County Road B, Suite 204 Roseville, MN
MN Couple Therapy Center 1611 County Road B, Suite 204 Roseville, MN 55113 651.340.4597 FULL NAME DATE DOB Presenting Problem 1. What is/are the reason(s) you are seeking therapy today? 2. Did a specific
More informationADULT HISTORY QUESTIONNAIRE
ADULT HISTORY QUESTIONNAIRE Date: Full Name: Date of Birth: If applicable, please complete the following: Partner s Name: Partner s Age: Partner s Occupation: IF YOU HAVE CHILDREN PLEASE LIST THEIR NAMES
More informationJourney to Truth Counseling
ADULT / COUPLE INTAKE FORM (Please Print) Date: / / Social Security # Date of birth: Age: Mr. Ms. Dr. Mrs. Miss. Rev. Full Name (Last) (First) (Middle) Parent/Guardian/Power of Attorney: (if applicable)
More informationADULT INITIAL EVALUATION: Patient Form
ADULT INITIAL EVALUATION: Patient Form Date: Patient: DOB: Referred by: Name of Person completing this form if not patient: Briefly describe the events that led to this appointment. Have there been any
More informationDemographic Information Form
PATIENT INFORMATION Demographic Information Form / / Mailing: Male Female SSN#: - - Home Cell Relationship Status (circle one): Single / Married / Divorced / Widowed / Other: ( ) - ( ) - (Preferred Phone
More informationAdult Information Form
1 Client Name: Age: DOB: Today s Date Address: City: State: Zip: Home Phone: ( ) Ok to leave message? YES NO Work Phone: ( ) Ok to leave message? YES NO Current Employer (or school if a student): Gender:
More informationLyris Bacchus Steuber, MS, LMFT MT Harley Lester Lane Apopka, FL Ph: , Fax:
Lyris Bacchus Steuber, MS, LMFT MT 2075 515 Harley Lester Lane Apopka, FL 32703 Ph: 407 417 7770, Fax: 407 862 4820 Please complete the following so I can have a better understanding of how I can help
More informationClient Information Form
Client Information Form General Information Date: Name: Date of Birth: Age: Current Address: Home Phone: Cell Phone: Best number and time to reach you directly: Can I leave a message at either or both
More informationCOUNSELING INTAKE FORM
COUNSELING INTAKE FORM Name Age Date Full Address Home Phone Work E-mail Work History Occupation How long? If presently unemployed, describe the situation Hobbies/Avocations Any past/present military service?
More informationADD/ADHD Patient Intake Form. Patients age 18 years or older
Lisa Sachdev, D.O. ADD/ADHD Patient Intake Form Patients age 18 years or older Please fill out the following questionnaire prior to your first appointment. You must be completely honest and detailed in
More informationName: Date: Who referred you? Current Psychiatrist: Clinical Information:
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
More informationCLIENT HISTORY CLIENT LEGAL NAME: CLIENT PREFERRED NAME:
CLIENT HISTORY CLIENT LEGAL NAME: DATE: CLIENT PREFERRED NAME: FAMILY & SOCIAL BACKGROUND Please list and describe your current family members (immediate, extended, adopted, etc.) and/or other members
More informationSANDSTONE PSYCHOLOGICAL PRACTICE
SANDSTONE PSYCHOLOGICAL PRACTICE Christina L. Aranda, Ph.D. & Janell M. Mihelic, Ph.D. CONTACT INFORMATION New Client Questionnaire Name: Date: Date of Birth: Age: _ Address: Preferred Phone Number: Type:
More informationDemographic Information Form
Demographic Information Form PATIENT INFORMATION Male Female Other / / (Patient Legal Last Name) (Patient Legal First Name) (MI) (DOB) Mailing: SSN#: - - Home Cell Relationship Status (circle one): Single
More informationADD/ADHD Assessment. for patients age 18 years or older. Name: Date of Birth: Age: Sex: Today s Date:
Lisa Sachdev, D.O. ADD/ADHD Assessment for patients age 18 years or older In order for us to be able to fully evaluate you, please fill out the following questionnaire to the best of your ability. We realize
More informationPinkston Psychology, LLC Ph. (318) Fx. (318) Completed this form Patient Spouse Parent Other
Pinkston Psychology, LLC Ph. (318) 553-5099 paula@pinkstonpsychology.com Fx. (318) 553-5338 ADULT HISTORY FORM Date Completed this form Patient Spouse Parent Other Patient s Name Date of Birth Age Sex
More informationFMS Psychology, PLLC Adult Intake Form. Phone Number (Day): Phone Number (Evening):
FMS Psychology, PLLC Adult Intake Form General Information: Name: Date of Birth: / / Age: Gender: Address: Phone Number (Day): Phone Number (Evening): Primary Care Physician: Highest Level of Formal Education:
More informationName Last First Middle Date. Completed by: If not client, relationship to client. Reason for Seeking Counseling:
CLIENT HISTORY (PSYCHOLOGICAL, SOCIAL, PHYSICAL and SPIRITUAL) Name Last First Middle Date Completed by: If not client, relationship to client Reason for Seeking Counseling: Personal Information Sex: [
More informationFull Circle Psychotherapy: Ayla Marie Carter, MA, LMHC
Full Circle Psychotherapy: Ayla Marie Carter, MA, LMHC aylacarter@fullcirclepsychotherapy.org www.fullcirclepsychotherapy.org (253) 686-4681 Name (First, Middle, last): Birthdate: Age: Gender: Sexual Orientation:
More informationThe Caring Center of Wichita LLC. General Information Client Name:
PERSONAL & SUBSTANCE ABUSE HISTORY Biological / Psychological / Social Assessment Assessors Name: Date of Assessment: General Information Client Name: Maiden (If Applicable): Date of Birth: Home Phone:
More informationAdult Information Form Page 1
Adult Information Form Page 1 Client Name: Age: DOB: Date: Address: City: State: Zip: Home Phone: ( ) OK to leave message? Yes No Work Phone: ( ) OK to leave message? Yes No Current Employer (or school
More informationAssociates of Behavioral Health Northwest CHILD/ADOLESCENT PSYCHOSOCIAL ASSESSMENT
CHILD/ADOLESCENT PSYCHOSOCIAL ASSESSMENT Name: Date: I. PRESENTING PROBLEM What events or stressors led you to seek therapy at this time? Check all that apply. Mood difficulties (i.e. sad or depressed
More informationNorthside Mental Health Center Intake Questionnaire
Name: _ Date of Birth: Age: SS# Address: City & State: Zip Code: GOALS How may we help you today? What type of help would you like? Circle all that apply Counseling Medication See a doctor What would you
More informationCERTIFICATION 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:
More informationMINOR CLIENT HISTORY
MINOR CLIENT HISTORY CLIENT NAME: DATE: FAMILY & SOCIAL BACKGROUND: Please list and describe your child s or teen s current family members (immediate, extended, adopted, etc.) NAME RELATIONSHIP AGE OCCUPATION
More informationADULT INFORMATION SHEET
ADULT INFORMATION SHEET Date / / Referred by: CLIENT INFORMATION Name: Age: D.O.B. / / Address: Apt#: City: State: Zip Code: Cell Phone: Home Phone: Other: Occupation: Place of employment: PRESENTING ISSUE
More informationIf so, when: Demographic Information Male Transgender Height: Weight: Massachusetts Resident? Primary Language: Are you currently homeless?
Application Form rev. 9/09 Jeremiah's Inn P.O. Box 30035 1059 Main St., Worcester, MA 01603-0035 FAX 508.793.9568 Phone 508.755.6403 Last Name: Suffix: First Name: Middle Initial: Alias: Referral Information
More informationPeople In Need Adult Intake Information Form (18 years old and up)
People In Need Adult Intake Information Form (18 years old and up) Date: Name: Client Case # Sex: Date of Birth: Social Security Number: - - Home Address: Work Address: Employer: Occupation: Referred by:
More informationName Last First Middle Date. Completed by: If not client, relationship to client: Reason for Seeking Counseling:
CLIENT HISTORY (PSYCHOLOGICAL, SOCIAL, PHYSICAL and SPIRITUAL) Name Last First Middle Date Completed by: If not client, relationship to client: Reason for Seeking Counseling: Sex: [ ] Male [ ] Female Place
More informationPSYCHOLOGICAL 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
More informationBecky Nickol, NCC, LMHC Licensed Mental Health Counselor, MH Wood Lake Drive Maitland, Florida
Becky Nickol, NCC, LMHC Licensed Mental Health Counselor, MH 8569 240 Wood Lake Drive Maitland, Florida 32751 407-831-7783 becky@beckynickol.com Adult Biopsychosocial Assessment General Information Date:
More informationHealth and Social Information 1. How is your physical health at present? (Please circle) Poor Unsatisfactory Satisfactory Good Very good
Client Health History and Background Please provide the following information for my records. Continue on the backside of this form if you need additional space. General Information Name: Date: Birth Date:
More informationName: Date: Gender: Family and Social. Family Constellation
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,
More informationJuniata College Health & Wellness Counseling Center INITIAL ASSESSMENT
Juniata College Health & Wellness Counseling Center INITIAL ASSESSMENT DATE Name Date of Birth Age Class Year Email Cell Hometown/State Emergency Contact Emergency Number Gender Identity Race/Ethnicity
More informationAdult Intake Form. Name: Date: Describe the problem that brought you here today: Briefly share relevant history behind this problem:
Adult Intake Form Date: Describe the problem that brought you here today: Briefly share relevant history behind this problem: Check any of the following symptoms that you are experiencing: Distractibility
More informationClient Name: Date of Birth: Address: City: Zip code: Hm #: ( ) -. Cell#: ( ) -. Wrk#: ( ) -. Otr#: ( ) -.
New Client Intake Date: Client Name: Date of Birth: Address: City: Zip code: Hm #: ( ) -. Cell#: ( ) -. Wrk#: ( ) -. Otr#: ( ) -. Employer Email: Emergency Contact Name Relationship Phone number TREATMENT
More informationCLIENT QUESTIONNAIRE. Preferred Name: Address: (Street) (City/State) (Zip Code) Home Phone: Cell Phone: Relationship: Cell Phone:
CLIENT QUESTIONNAIRE Full Legal Name: DOB: / / Preferred Name: Email: Address: (Street) (City/State) (Zip Code) Home Phone: Cell Phone: Can we leave voice messages for you at these numbers? Yes Text Messages?
More informationSECTION 2: CURRENT CONCERNS Briefly describe the current concerns you would like to discuss with your counselor:
Page 1 Amarillo College Counseling Center Intake Packet The following information is needed to best serve you. Please clearly print your response to each question. SECTION I: IDENTIFYING INFORMATION Today
More informationChristina Pucel Counseling 416 W. Main St Monongahela, PA /
ADULT INTAKE Name: Gender: M F DOB: Address: City: State: Zip: Telephone: Home Mobile Highest Level Education: Occupation: Emergency Contact: Relationship: Phone: Referred by: Family Members: Name Gender
More informationHealth History Form. Date of Birth: / / Reason for today s visit:
Insight Medical Group LLC Health History Form Name: Date of Birth: / / Reason for today s visit: CURRENT MEDICATIONS Name of Medication Strength (ex. 500 mg) Dosing Instructions (ex. Twice a day) ALLERGY
More informationPATIENT HISTORY DATA FORM Psychiatric, Health and Wellness, LLC 810 Michael Drive, Suite L Chesterton, IN NAME
PATIENT HISTORY DATA FORM Psychiatric, Health and Wellness, LLC 810 Michael Drive, Suite L Chesterton, IN 46304 PRINT THIS FORM, COMPLETE AND BRING WITH YOU (DO NOT COMPLETE ONLINE) : NAME: LAST FIRST
More informationKatarina R. Mansir, Psy.D. Licensed Psychologist PSY25417 (858) Name: Date: Presenting Concerns
Name: Date: Presenting Concerns Briefly describe what brings you to therapy. Approximately how long has this concern been bothering you? Day Week Month Several months Year Several years Most of my life
More informationHealth History Form. Date of Birth: / / Reason for today s visit:
www.lifegrouprecovery.com Health History Form Name: Date of Birth: / / Reason for today s visit: CURRENT MEDICATIONS Name of Medication Strength (ex. 500 mg) Dosing Instructions (ex. Twice a day) ALLERGY
More informationChild and Youth Background Information
Child and Youth Background Information CHILD S NAME: SUBSTANCE USE HISTORY (for ages 12 and older or if applicable) Substance Type Current Use (last 6 months) Past Use: Please check and complete all that
More informationx S. Broadway, Suite 7 Pitman, NJ Intake Form
Intake Form Name: Date: *If attending couples or family therapy please complete one form for each individual attending treatment. Presenting Problems and Concerns Describe the Problem that brought you
More information2550 Middle Road, Suite 316 Bettendorf, Iowa Adult Intake Form
Adult Intake Form 2550 Middle Road, Suite 316 Bettendorf, Iowa 52722 563.265.1529 annika@qcwomenstherapy.com Thank you for choosing Quad City Women s Therapy. I collect the following information help me
More informationJILL L. KOFENDER, PHD, PLLC. Licensed Clinical Psychologist ADULT CLIENT QUESTIONNAIRE. Client s Name Today s Date Gender Age Birthdate
JILL L. KOFENDER, PHD, PLLC Licensed Clinical Psychologist ADULT CLIENT QUESTIONNAIRE Client s Name Today s Date Gender Age Birthdate Cell Phone Is it ok to text? Y N Is it ok to receive appt. reminders?
More informationEvergreen Behavioral Health Psychiatric Intake Form. Name: Date: Date of Birth:!
Name: Date: Date of Birth: NOTE: Please also fill out the standard Evergreen Behavioral Health Adult Client Information form to accompany this one if you have not yet done so. Please also bring in recent
More informationClient Information Form
Today s Date: Client Information Form Note: If you have been a client here before, please fill in only the information that has changed. If you are seeking services as a couple, each member must complete
More informationClient Intake Form. Briefly describe the reason(s) you are seeking psychotherapy at this time:
Client Intake Form Thank you for taking the time to openly and honestly answer the questions below. Your genuine responses are appreciated, as all information provided will assist your therapist to better
More informationPATIENT INTAKE: MEDICAL AND SOCIAL HISTORY (To be completed by patient)
NAME: DOB: Today's date: PATIENT INTAKE: MEDICAL AND SOCIAL HISTORY (To be completed by patient) Use the opposite side of the page as necessary to complete your answers. Please print legibly. Patient Name
More informationBIOPSYCHOSOCIAL SCREENING ADULT
BIOPSYCHOSOCIAL SCREENING ADULT CHART NUMBER: DOB: 1. IDENTIFYING INFORMATION Client Name: Availability: Family Member Name: Availability: Family Member Phone Numbers: Telephone (Day): Telephone (Eve):
More informationDiana Valdez, PhD, LPC
Diana Valdez, PhD, LPC 1701 River Run, Suite 1107, Fort Worth, TX 76107 (817) 332-1425 dianavaldezphd@gmail.com ADULT BACKGROUND Name Date of Birth Street Address City, State, Zip Home/Cell Phone Work
More informationBehavior Health Admission Information Form. Name Date
Behavior Health Admission Information Form Name Date What symptoms are you experiencing? Depressed Mood Anxiety Agitation Hopelessness Suicidal Thoughts Worthlessness Guilt Anger Difficulty Concentrating
More informationRestore Counseling Center 630 E Southlake Blvd, Ste 127, Southlake, Tx
Adult Information Restore Counseling Center 630 E Southlake Blvd, Ste 127, Southlake, Tx 76092 817-614-1488 Dx code: Welcome to Restore Counseling Center. In order for us to gain a better understand of
More informationSAMPLE. Date of Birth: Age: Gender: Woman: Man: Transgender: Transman: Transwoman: Gender Nonconforming: Other:
Patient Intake Questionnaire Note: This is a sample intake questionnaire which includes a wide variety of potential questions that can be asked of new clients during the intake process. Providers are encouraged
More informationMINDFUL WELLNESS CENTER, PLLC
PATIENT HISTORY NAME DATE PLEASE TAKE YOUR TIME AND COMPLETE THE ENTIRE FORM. You may use the back if needed for more explanation. Identifying Information: Date of Birth: Age: Sex: Place of Birth: Religion:
More informationDriftwood 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:
More information*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
More informationNarrative Report - ASI-MV Addiction Severity Index - Multimedia Version
Site: Inflexxion Address: 320 Needham St., Newton MA 02464 Summary of Results for: Narrative Report - ASI-MV Addiction Severity Index - Multimedia Version Client Name: John Doe Client ID: 987654MM Client
More informationADULT INFORMATION FORM
ADULT INFORMATION FORM Instructions: To assist in helping you, please fill out this form as fully and openly as possible. All private information is held in strictest confidence within legal limits. Name:
More informationSofia P. Simotas, Ph.D., PLLC 2524 Nottingham St. Houston, Texas 77005
Sofia P. Simotas, Ph.D., PLLC 2524 Nottingham St. Houston, Texas 77005 INTAKE FORM Name: Date: Gender: Female Male Date of birth: Address: Home phone: Cell: Okay to leave a message? Yes No Email: Emergency
More informationSan Diego Center for the Treatment of Mood Disorders 1
San Diego Center for the Treatment of Mood Disorders 1 DATE NAME Last Middle First REFERRAL HISTORY: How did you find us (via a referral, web search, recommendation)? Please provide the name and phone
More informationA New Tomorrow Behavioral Health Services
A New Tomorrow Behavioral Health Services Tara L. Corbett MS, LPC Jenais Y. Means MA, LPC-I Linda L. Leech PhD, LPC, LPC-S Natasha Moseng MS, LPC-I 2635-A Hardee Cove, Sumter, S.C. 29150 Phone: (803) 883-4981
More informationPsychiatric Nurse Practitioner Intake Form. General Information. 1. Name. 2. Date of Birth. 3. Age. 4. Gender. 5. Referred by
Psychiatric Nurse Practitioner Intake Form General Information 1. Name 2. Date of Birth 3. Age 4. Gender 5. Referred by 6. Emergency Contact & Phone Number 7. Please State your Main Reason for Coming in
More informationTo be completed by Patient. Client Questionnaire
Date: To be completed by Patient Client Questionnaire Client(s) Name: SSN#: - - Name of Person Completing Form: Relationship to Patient: (if other than client) Marital Status of Client Race/Ethnic Origin
More informationMental Health Intake Form
Current Symptoms Checklist: (check once for any symptoms present, twice for major symptoms) ( ) ( ) Depressed mood ( ) ( ) Racing thoughts ( ) ( ) Excessive worry ( ) ( ) Unable to enjoy activities ( )
More informationPHARMACY 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
More informationMERLE MULLINS COUNSELING REGISTRATION FORM (Please Print) CLIENT INFORMATION
MERLE MULLINS COUNSELING REGISTRATION FORM (Please Print) CLIENT INFORMATION Last Name: First: Middle:! Mr.! Mrs. Today s date: / /! Miss! Ms. Marital status (circle one) Single / Mar / Div / Sep / Wid
More informationADULT INTAKE QUESTIONNAIRE. Ok to leave message? Yes No. Present psychological difficulties please check any that apply to you at this time.
ADULT INTAKE QUESTIONNAIRE Name: Today s Date: Age: Date of Birth: Address: Home phone: Work phone: Cell phone: Ok to leave message? Yes No Ok to leave message? Yes No Ok to leave message? Yes No Email:
More informationLast Name First Middle Date of Birth Age. Residence Address City State Zip Code
The following necessary information will help make your first session most productive. Please PRINT and fill out this form COMPLETELY. DEMOGRAPHICS Date: Last Name First Middle Date of Birth Age Residence
More informationADULT QUESTIONNAIRE. What have you been told with regard to the problem?
1 ADULT QUESTIONNAIRE Please complete this 2-sided questionnaire. Write N/A when a question is not applicable. Date: Full Name: Birth Date: Age: Sex: Home Address: Telephone: City: State: Zip Code: Email:
More informationELEMENTAL CENTER MENTAL HEALTH INTAKE FORM
1 Please complete all information on this form. It may seem long, but most of the questions require only a check, so it will go quickly. Thank You! Personal Information First Name Last Name Gender DOB
More informationAlcorn & Allison. clinical associates **C O N F I D E N T I A L**
Alcorn & Allison clinical associates **C O N F I D E N T I A L** ADULT INITIAL INTAKE ASSESSMENT *Please fax your completed form to 630.469.4911 prior to your first session. If you are unable to do so,
More informationLEXIE SMITH LPC 116 W. 7th, Suite 211 Stillwater, OK Date. Personal History Information
1 LEXIE SMITH LPC 116 W. 7th, Suite 211 Stillwater, OK 74074 405-707-9600 Date Personal History Information Client's Name Referred By Address Phone City/State/Zip Birthdate Age Occupation Employed by Social
More informationPERSONAL HISTORY NAME TODAY S DATE LAST FIRST MI LIST ANY ADDITIONAL NAMES USED: ADDRESS PHONE (STREET) (CITY) (STATE) (COUNTY) (ZIP)
PERSONAL HISTORY PERSONAL INFORMATION: NAME TODAY S DATE LAST FIRST MI LIST ANY ADDITIONAL NAMES USED: ADDRESS_ PHONE (STREET) (CITY) (STATE) (COUNTY) (ZIP) AGE: DATE OF BIRTH: SOCIAL SECURITY #: RACE:
More informationAddress: 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:
More informationChild & Adolescent Life History Questionnaire. Moving Forward Counseling, LLC Middlebelt Road, Suite 100-C Farmington Hills, MI 48334
Child & Adolescent Life History Questionnaire Moving Forward Counseling, LLC 32813 Middlebelt Road, Suite 100-C Farmington Hills, MI 48334 Please answer these questions to the best of your ability so that
More informationMinor Intake Form. Child s Name DOB
Page 1 of 5 Minor Intake Form Child s NameDOB Current Concerns: What concern brings you or your child in? When did this concern begin? (Please attempt to use dates.) Has your family/child been in therapy
More information5975 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
More informationLife, Family and Relationship Questionnaire
Date of Initial Session: Client Name Date of Birth Address City Zip Phone Number Email Emergency Contact Relationship Emergency Contact Ph. # Client Name: Date: Life, Family and Relationship Questionnaire
More informationHenrike B. Kroemer, Ph.D. ADULT HISTORY FORM
INTRODUCTORY INFORMATION Henrike B. Kroemer, Ph.D. ADULT HISTORY FORM Date completed Name Date of Birth (last) (first) (middle) Address Telephone: home work cell Email address Soc Sec # Gender Marital
More informationSec on 1 Demographic Informa on
The Priority Care Center A Program of the Humboldt IPA Primary Care Physician: Sec on 1 Demographic Informa on How were you referred: Name (Last, First, M.I.): A.K.A.: Date of Birth: Mailing Address: /
More informationApplication and History for Adult
Application and History for Adult Please print clearly. Complete as much information as possible. This information will be discussed with your counselor. Today s Date: First Name: Middle Initial: Last
More informationMedications. New Patient Registration. Billing and Insurance. Phone Calls. Prescription Refills. Lab Results and Test Results
Dear New Patient: We would like to welcome you to our practice. Our goal is to make your experience with us as pleasant as possible. In order to help us meet this goal we have listed some helpful hints
More information