LIFE INTEGRATION THERAPIES, PC., INC. KAY WHITEHEAD, MSW., LCSW., FT. 23 E.39 th St. INDIANAPOLIS, IN CLIENT HISTORY FORM
|
|
|
- Bertina Goodman
- 5 years ago
- Views:
Transcription
1 LIFE INTEGRATION THERAPIES, PC., INC. KAY WHITEHEAD, MSW., LCSW., FT. 23 E.39 th St. INDIANAPOLIS, IN CLIENT HISTORY FORM Name Date Address City St Zip Home Phone Work Cell (if I may contact you by ) Date of birth Who referred you? Occupation/Employer How long? Are you: (please circle) Single Married/Permanent Partner Divorced Widowed Living Together Separated If you are in a relationship, how long have you been in it and what is the quality of the relationship? If divorced or separated when did this occur and for what reason? If widowed, please explain your loss, when it happened, and the circumstances around the death. Who else lives in your household? (Name, age, gender) Emergency contact: Name Relationship Phone Have you ever seen other therapists or mental health counselors before? Y N What is the name of your previous therapist if you have had one/more? Have you seen a psychiatrist before? Who? And what have they given as your diagnosis? 1
2 What brings you to therapy at this time? If your reason for coming to therapy is grief/loss /life transition related, and not covered above, please describe it here. Explain as much as you are able. Feel free to use the back of the paper if you would like to add more. Have you seen another therapist for this current problem before? What have you already tried to do about the problem? Has any of it helped? What are your fears about therapy? What are your hopes and expectations? Do you have a good support system or circle of friends? How much do you currently drink alcohol, use drugs, smoke various things, or have any addiction to alcohol, drugs, food, sex, porn, gambling, shopping, relationships, or any other addictive substance or process, etc? If so what and how much a day? Is your alcohol or drug use, or whatever addictive behavior you have, a problem for you or has someone else said they think it is a problem for you and are concerned about your it? Please explain as much as you can. Feel free to use the back of the paper. If you or someone else thinks it is a problem, is there something you would like to do about it? Are you currently or have you been in any kind of a recovery program for alcohol, drug or other addictions, eating disorders, sex addiction, porn, gambling, shopping, relationships, codependency, smoking or any other addiction or something like an addiction? Please circle. If yes, how long, and what is the quality of your recovery program? What recovery program are you in? Are you working with a sponsor or involved in a self-help group for support? 2
3 Do you have a history of having any kind of abuse done to you? (Physical, sexual, verbal, emotional, spiritual, etc?) Please explain as much as you are able. Have you ever abused anyone? Explain as much as you are able. Is there any current abuse being done to you, by you or being done by someone else in your household? Feel free to use the back of the paper. Is there any history of any addiction, abuse, or mental illness in your family of origin or the family that raised you? If yes, please describe. Perhaps it was something not openly discussed, or maybe you are aware that someone in the family completed suicide or some other problem occurred. Have you ever felt or acted suicidal? Have you been hospitalized for this? Do you feel this way now? Do you have a plan? Do you have the means to carry it out? Please explain, I really do want to know especially if you haven t had a chance to talk about it. Please describe your spiritual beliefs or practices if any. (Anything from meditation, journaling, walking in nature, yoga, to formal religious practice and going to church, bible study whatever you consider spiritual, but not drug or alcohol induced). Does your spiritual practice help you cope with life stressful life events? How is your current physical health? What significant illness, surgeries, or hospitalizations have you had? Please list. 3
4 Have you had any other kind of trauma that has not been covered in other information already asked? Please describe. (A trauma is what you consider traumatic, not what the general population might consider traumatic. It could be a car accident, a horrible argument, or anything that is painful or shameful, where you felt you were in danger, you felt your life was threatened or you have had recurring intruding thoughts about something that was painful, shameful, frightening, threatening or dangerous, etc). Please include instances of bullying, name calling, horrible teasing, being shamed in public, etc. If you need to, use the back of the paper. And how have you coped? What do you do for fun, entertainment, exercise, relaxation? What medications are you taking and the reason for them? (Please list especially medications such as: antidepressants, mood stabilizers, and anxiety medications, plus anything else prescribed or supplements of any kind etc.). Please list other health care practitioners you are currently seeing or with whom you consult and why. What is the highest level of education you have attained? Are you currently in school of any kind, including online classes? Please name your siblings and their ages, if you have any. Is any family of origin members or close family/friends deceased or ill? If yes, who? 4
5 Have there been any developmental, educational, social or physical delays that you have experienced? If yes, please list. Any special achievements? Have you been or are you a member of the armed forces? Have you been or are you a member of the Peace Corps or some other similar organization? What do you see as your strengths and limitations? Please circle any of the following words that describe you now: ACTIVE AMBITIOUS MOODY SELF-CONFIDENT PERSISTENT NERVOUS HARDWORKING INPAITIENT IMPULSIVE KINDLY OFTEN-BLUE EXCITABLE IMAGINATIVE CALM SERIOUS EASY-GOING SHY GOOD-NATURED QUIET INTROVERT EXTROVERT LIKEABLE LEADER LONELY SUBMISSIVE HARDENED SPIRITUAL SELF-CONSCIOUS REGIMENTED SENSITIVE FEARFUL ANXIOUS SAD HAPPY Is there anything else that would be helpful for me to know as we start therapy? Anything about: What motivates you? Your learning style? How you cope with new information? What helps you when you are frightened? What you need from me as your therapist? Whatever crosses your mind that you think is useful for our time together. I really want our time to be helpful and useful for you. If you don t know what works for you, are you willing to try new things? Please answer on the back of this page. Would you like to receive periodic newsletter updates? Circle One: Yes No Client Signature Date 5
Client 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
CONFIDENTIAL. Name Today s Date. Address: City: State: Zip: Phone number (cell): (home): (work): address: Emergency Contact (name): (number):
INTAKE FORM CONFIDENTIAL Name Today s Date Contact information: Date of birth Address: City: State: Zip: Phone number (cell): (home): (work): Email address: May I leave a voicemail on your cell or home
Chapter 1. Dysfunctional Behavioral Cycles
Chapter 1. Dysfunctional Behavioral Cycles For most people, the things they do their behavior are predictable. We can pretty much guess what someone is going to do in a similar situation in the future
Humanistic Psychological Services 831 Alamo Drive, Suite 5C, 6B, 6C Vacaville, CA Phone: (707) FAX: (707)
Humanistic Psychological Services 831 Alamo Drive, Suite 5C, 6B, 6C Vacaville, CA 95688 Phone: (707) 624-9767 FAX: (707) 471-4140 Intake Paperwork for Adult Today s Date Referred By Please take time to
Neurobiology of Sexual Assault Trauma: Supportive Conversations with Victims
Neurobiology of Sexual Assault Trauma: Supportive Conversations with Victims Jim Hopper, Ph.D. November 2017 Handout 1: Using Neurobiology of Trauma Concepts to Validate, Reassure, and Support Note: In
CLIENT INTAKE FORM. Please describe your main reason(s) for seeking services at this time?
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
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
Restore 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
Life, 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
C O U P L E S I N T A K E F O R M
COUPLE S INTAKE FORM CONFIDENTIAL Name Today s Date Contact information: Address: City: State: Zip: Phone number (cell): (home): (work): Email address: Date of Birth May I leave a voicemail on your cell
COUNSELING 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?
Support for Kidney Cancer
Page 1 Fact sheet Introduction Our series of kidney cancer fact sheets have been developed to help you understand more about kidney cancer. This fact sheet provides support information for people affected
BETHESDA WORKSHOPS: HEALING FOR MEN PARTICIPANT INFORMATION FORM
BETHESDA WORKSHOPS: HEALING FOR MEN PARTICIPANT INFORMATION FORM Name Age Preferred first name Address City, State Zip Phone (Day) -_- Cell --_ Email address Occupation (indicate former occupation if retired)
Full 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:
Depression: what you should know
Depression: what you should know If you think you, or someone you know, might be suffering from depression, read on. What is depression? Depression is an illness characterized by persistent sadness and
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:
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
Name: 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
Handouts for Training on the Neurobiology of Trauma
Handouts for Training on the Neurobiology of Trauma Jim Hopper, Ph.D. April 2016 Handout 1: How to Use the Neurobiology of Trauma Responses and Resources Note: In order to effectively use these answers,
Step One. We admitted we were powerless over our addictions and compulsions --that our lives had become unmanageable.
Step One We admitted we were powerless over our addictions and compulsions --that our lives had become unmanageable. I know that nothing good lives in me, that is, in my sinful nature. For I have the desire
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:
A report about. Anxiety. Easy Read summary
A report about Anxiety Easy Read summary Mental Health Awareness Week 2014 This is an Easy Read summary of the Living with Anxiety report (2014). This report was written by the Mental Health Foundation.
Diana 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
Depression Care. Patient Education Script
Everybody has the blues from time to time, or reacts to stressful life events with feelings of anxiety, sadness, or anger. Normally these feelings go away with time but when they persist, and are present
AT RISK YOUTH ASSESSMENT YAR application/assessment must be reviewed with YAR coordinator prior to being filed
Court Services At-Risk Youth Drug/Alcohol Services Probation Drug Court Diversion Detention CASA Truancy CLALLAM COUNTY JUVENILE & FAMILY SERVICES Peter A. Peterson Director 1912 West 18th Street Port
Mental Health is for Everyone
Mental Health is for Everyone Promoting Mental Health In Adults This resource is to promote mental health. For crisis help: Call 911 Visit your nearest hospital emergency department What s Inside What
A VIDEO SERIES. living WELL. with kidney failure LIVING WELL
A VIDEO SERIES living WELL with kidney failure LIVING WELL Contents 2 Introduction 3 What will I learn? 5 Who is on my healthcare team? 6 Who is affected by kidney failure? 6 How does kidney failure affect
ADULT INTAKE FORM. Name
Welcome to Solace Counseling Associates. Please note that the information is important for your care. Please fill out forms as completely as possible and have them ready before your first counseling session.
BACKGROUND HISTORY QUESTIONNAIRE
BACKGROUND HISTORY QUESTIONNAIRE Name: Sex M F Address: Home Number: Work Number: Cell Number: Email: SSN: Name and Address of Employer: Date of Birth: Age: Ethnicity: Referred By: Referral Question or
The Impact of the Opioid Crisis on Children
The Impact of the Opioid Crisis on Children Guided Notes for Online Learning Name: Date: 1 Table of Contents Section 1: The Opioid Crisis Page 3 Section 2: Addiction Page 4 Section 3: Trauma Informed Care
Deborah L. Galindo, Psy.D th St. SE, Ste 420 Salem, OR Phone: Fax: (503) or (503)
Deborah L. Galindo, Psy.D. 2601 25 th St. SE, Ste 420 Salem, OR 97302 Phone: 503-364-6093 Fax: (503) 566-9864 or (503) 364-5121 COUPLES THERAPY INTAKE QUESTIONNAIRE (EACH PARTNER NEEDS TO COMPLETE THIS
ADULT 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
We all have our share of good days and bad. After all, life is filled with. many ups and downs. Some days may be so bad that we have trouble doing
A Publication of the Amputee Coalition of America About Depression First Step - Volume 4, 2005 Easy Read Original article by Bill Dupes Translated into plain language by Helen Osborne of Health Literacy
did you feel sad or depressed? did you feel sad or depressed for most of the day, nearly every day?
Name: Age: Date: PDSQ This form asks you about emotions, moods, thoughts, and behaviors. For each question, circle YES in the column next to that question, if it describes how you have been acting, feeling,
Health 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:
Class #2: ACTIVITIES AND MY MOOD
Class # Class #: ACTIVITIES AND MY MOOD CLASS OUTLINE I. Announcements & Agenda II. III. IV. General Review Personal Project Review Relaxation Exercise V. New Material VI. Personal Project I. Any Announcements?
Sleep Health Center. You have been scheduled for an Insomnia Treatment Program consultation to further discuss your
Sleep Health Center You have been scheduled for an Insomnia Treatment Program consultation to further discuss your sleep. In the week preceding your appointment, please take the time to complete the enclosed
SOS Signs of Suicide. Some Secrets SHOULD be Shared
SOS Signs of Suicide Some Secrets SHOULD be Shared Let s talk for a moment about Depression True or False? Depression is more than just feeling sad. True! Feeling depressed means you might feel some or
Depression. Your guide to depression and finding the help and support you need
Depression Your guide to depression and finding the help and support you need 80,000 Nearly 80,000 children and young people suffer from depression in the UK. Depression is one of the most common types
What I Want From Treatment User Information
What I Want From Treatment User Information The tailoring to treatment to individual needs has long been lauded, but often it is designing treatment to what the counselor thinks the client needs. This
Adult 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:
Hope Begins with You. Jeff Morris, Presenter
Hope Begins with You. Jeff Morris, Presenter What do you want to learn? How to help someone who is depressed. How to help family members of a depressed person. How to identify students who are high-risk.
ADULT 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
ALVIN C. BURSTEIN, MD PATIENT CLIENT INFORMATION
ALVIN C. BURSTEIN, MD PATIENT CLIENT INFORMATION LEGAL Name Date of Birth (must match insurance card) Address City State Zip Mailing Address City State Zip (If different) Phone: Cell Home Appt. reminders
Adult 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
Demographic Information Form
PATIENT INFORMATION Demographic Information Form / / Mailing: Male Female SSN#: - - Home Cell Relationship Status (circle one): Single / Married / Divorced / Widowed / Other: ( ) - ( ) - (Preferred Phone
Having suicidal thoughts?
Having suicidal thoughts? Information for you, and for family, whänau, friends and support network Prepared by skylight for the New Zealand Guidelines Group CONTENTS Having Suicidal Thoughts? 1 Asking
CLIENT 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?
Non-epileptic attacks
Non-epileptic attacks A short guide for patients and families Information for patients Neurology Psychotherapy Service What are non-epileptic attacks? Non-epileptic attacks are episodes in which people
After Adrenal Cancer Treatment
After Adrenal Cancer Treatment Living as a Cancer Survivor For many people, cancer treatment often raises questions about next steps as a survivor. Lifestyle Changes After Treatment for Adrenal Cancer
Emotional Changes After a Traumatic Brain Injury
Emotional Changes After a Traumatic Brain Injury EMOTIONAL LABILITY Emotional lability can be caused by damage to the parts of the brain that control emotion. Some people with Traumatic Brain Injury or
Post-Traumatic Stress Disorder
Post-Traumatic Stress Disorder Teena Jain 2017 Post-Traumatic Stress Disorder What is post-traumatic stress disorder, or PTSD? PTSD is a disorder that some people develop after experiencing a shocking,
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
Client Intake History
Client Intake History Brianna Johnston, LMFT 100 Sawmill Rd, Suite 3101 Lafayette, IN 47905 Instructions: To assist in helping you, please fill out this form as fully and openly as possible. All private
Last 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
Coping with Cancer-Related Worry and Sadness
Patient & Family Guide 2018 Coping with Cancer-Related Worry and Sadness www.nscancercare.ca Coping with Cancer-Related Worry and Sadness Having cancer can be very stressful. It may cause changes in your
Atlanta Psychological Services
Atlanta Psychological Services 2308 Perimeter Park Drive 770-457-5577 Suite 100 Fax 770-457-5599 Atlanta, GA 30341 atlantapsychological.com Check one: rev. 10-13-18 J. Todd George, PsyD Carolyn Johnson,
A-TIP Acute -Traumatic Incident Procedures Roy Kiessling, LISW, ACSW
A-TIP Acute -Traumatic Incident Procedures Roy Kiessling, LISW, ACSW roykiessling@me.com This brief model (3-6 sessions) contains/restricts the processing for clients who have experienced a recent trauma
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,
Journey 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)
RELAPSE PREVENTION THERAPY
RELAPSE PREVENTION THERAPY Stages of Change Model (Prochaska & Diclemente, 1992) Relapse Prevention Abstinence Lapse- first episode of drug intake after a period of abstinance Relapse- episode of backsliding
STAR-CENTER PUBLICATIONS. Services for Teens at Risk
STAR-CENTER PUBLICATIONS Services for Teens at Risk Teen Handbook on Depression Services for Teens at Risk (STAR-Center) Western Psychiatric Institute and Clinic (412)864-3346 All Rights Reserved - 2018
MOOD CHANGES IN MULTIPLE SCLEROSIS DISCUSSION GUIDE AND FAQ
MOOD CHANGES IN MULTIPLE SCLEROSIS DISCUSSION GUIDE AND FAQ Contents Introduction...1 Resources...3 Presentation Format...2 Program Survey...3 Group Discussion Questions...4 Frequently Asked Questions...6
Expert Strategies for Working with Anxiety
Expert Strategies for Working with Anxiety Bonus 1 - Transcript - pg. 1 Expert Strategies for Working with Anxiety An EMDR Approach for Healing Generalized Anxiety Disorder with Laurel Parnell, PhD; Rick
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
Client 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
By Brianne Masselli and Johanna Bergan Youth M.O.V.E. National. A Guide for Youth. Understanding Trauma
By Brianne Masselli and Johanna Bergan Youth M.O.V.E. National A Guide for Youth Understanding Trauma For National Technical Assistance Center for Children s Mental Health Georgetown University Center
MN 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
Mental Health Information For Teens, Fifth Edition
Teen Health Series Mental Health Information For Teens, Fifth Edition Health Tips About Mental Wellness And Mental Illness Including Facts About Recognizing And Treating Mood, Anxiety, Personality, Psychotic,
TEEN DEPRESSION Why? What can help?
TEEN DEPRESSION Why? What can help? 3 COVER SUBJECT TEEN DEPRESSION Why? What Can Help? According to reports, the number of teens being diagnosed with depression is increasing at an alarming rate. What
Elana 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
A Guide to Understanding Self-Injury
A Guide to Understanding Self-Injury for Those Who Self-Injure What is Non-Suicidal Self-Injury? Non-Suicidal Self-Injury (NSSI), also referred to as self-injury or self-harm, is the deliberate and direct
In-Home Aides Partners in Quality Care - December
In-Home Aides Partners in Quality Care - December 2014 - In-Home Aides Partners in Quality Care is a monthly newsletter published for member agencies. Copyright AHHC 2014 - May be reproduced for In- Home
Lyris 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
Building Emotional Self-Awareness
Building Emotional Self-Awareness Definition Notes Emotional Self-Awareness is the ability to recognize and accurately label your own feelings. Emotions express themselves through three channels physically,
Choice Counseling Associates
Amy Vitacolonna, MS, LMHCA, RT/CT 719 Sleater-Kinney Rd SE, Suite 212 Lacey, WA 98503 (360) 349-8775 (office) (360) 584-9048 (fax) ChoiceCounselingAssociates@gmail.com ChoiceCounselingAssociates.com Choice
The 5 Things You Can Do Right Now to Get Ready to Quit Smoking
The 5 Things You Can Do Right Now to Get Ready to Quit Smoking By Charles Westover Founder of Advanced Laser Solutions Copyright 2012 What you do before you quit smoking is equally as important as what
Courage is resistance to fear, mastery of fear not absence of fear. ~Mark Twain
Courage is resistance to fear, mastery of fear not absence of fear. ~Mark Twain Now that we ve learned about many of the skills you ll see in CBT, let s talk about how to put them all together. This section
JILL 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?
How to Help Your Patients Overcome Anxiety with Mindfulness
How to Help Your Patients Overcome Anxiety with Mindfulness Video 11 - Transcript - pg. 1 How to Help Your Patients Overcome Anxiety with Mindfulness Why Future Goals Can Ease the Power of Anxiety with
Understanding Complex Trauma
Understanding Complex Trauma Frightening events can have lasting effects Trauma and Homelessness Team Carswell House Dennistoun Glasgow G31 2HX Tel: 0141 232 0114 Fax: 0141 232 0131 General enquiries email:
TOOL 1: QUESTIONS BY ASAM DIMENSIONS
TOOL 1: QUESTIONS BY ASAM DIMENSIONS The following tool highlights specific questions that should be asked of the patient for each ASAM dimension. Name Date of Birth Date of Interview Address Referred
Worries and Anxiety F O R K I D S. C o u n s e l l i n g D i r e c t o r y H a p p i f u l K i d s
Worries and Anxiety F O R K I D S C o u n s e l l i n g D i r e c t o r y H a p p i f u l K i d s Contents What is anxiety? Types of anxiety What does anxiety look like? Top tips for tackling worries Asking
Addictive Disorders Assessment Form
Addictive Disorders Assessment Form Thorpe Recovery Centre Telephone: 780.875.8890 Fax: 780.875.2161 Email: info@thorperecoverycentre.org CLIENT INFORMATION First Name Middle Name Last Name Phone Number
Here are a few ideas to help you cope and get through this learning period:
Coping with Diabetes When you have diabetes you may feel unwell and have to deal with the fact that you have a life long disease. You also have to learn about taking care of yourself. You play an active
Depression. Northumberland, Tyne and Wear NHS Trust (Revised Jan 2002) An Information Leaflet
Depression Northumberland, Tyne and Wear NHS Trust (Revised Jan 2002) An Information Leaflet practical ldren 1 7XR isle, d n. ocial These are the thoughts of two people who are depressed: I feel so alone,
Christina 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
Become a Partner with Your Clinician to Improve Your Health
What is health? You may think this is a simple question or even a silly one. Everyone knows that being healthy means not feeling sick or having a disease. Right? But health is more than this. The World
Mental Health Referral Form
Mental Health Referral Form Mailing Address: Niagara Region Mental Health 3550 Schmon Parkway, Second Floor, Unit 2 P.O. Box 1042 Thorold, ON L2V 4T7 905-688-2854 Toll free: 1-888-505-6074 niagararegion.ca/health
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
SAMPLE. 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
Managing Psychosocial and Family Distress after Cancer Treatment
Managing Psychosocial and Family Distress after Cancer Treatment Information for cancer survivors Read this pamphlet to learn: What psychosocial distress is What causes distress What you can do Where to
HANDOUTS FOR MODULE 7: TRAUMA TREATMENT. HANDOUT 55: COMMON REACTIONS CHECKLIST FOR KIDS (under 10 years)
HANDOUTS FOR MODULE 7: TRAUMA TREATMENT PARENT SESSION 1 HANDOUT 52: COMMON REACTIONS TO TRAUMA AND STRESS HANDOUT 53: MY CHILD S TRAUMA HISTORY CHILD SESSION 1 HANDOUT 54: PREVALENCE GRAPHICS HANDOUT
APPENDIX. TKJ Forms. The following forms have been created by TKJ in conjunction with this training manual:
APPENDIX TKJ Forms The following forms have been created by TKJ in conjunction with this training manual: Form 1 : Functional Assessment Form 2 : Brief Functional Assessment Interview Form Form 3 : Behavior
What To Expect From Counseling
Marriage Parenting Spiritual Growth Sexuality Relationships Mental Health Men Women Hurts and Emotions Singles Ministers and Mentors Technology a resource in: Mental Health What To Expect From Counseling
CLIENT 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
Optimal Health Questionnaire
Optimal Health Questionnaire This questionnaire is intended to help you assess how well you are balancing the various elements in your life. The basis of the process is that we have 5 dimensions which
FOREVER FREE STOP SMOKING FOR GOOD. Stop Smoking. For Good. Smoking, Stress, & Mood
B O O K L E T 6 Stop Smoking For Good Smoking, Stress, & Mood Contents What Causes Stress? 2 What is Stress? 4 How is Stress Related to Smoking? 4 So, Why Not Smoke When Stressed? 6 Better Ways to Deal
Determining Major Depressive Disorder in Youth.
Co-parenting chapter eight. Watching for Depression in Yourself and Your Child. by Yvonne Sinclair M.A. If you notice your child has been feeling sad most of the day and can t seem to shake that down feeling,
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: