Center for Transformative Counseling, Inc. 801 Georgia Street Key West, FL
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- Norma Haynes
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1 Center for Transformative Counseling, Inc. 801 Georgia Street Key West, FL Identifying Information Counseling Intake Name Nickname/Name you want to be called Address Phone Numbers (home, work, cell) Address Date of Birth Gender Ethnicity Marital/partnership status Close friend/relative we may contact in case of an emergency Relationship to you Address Phone Number Referred by *Note: If you need more space to answer any of the questions below, please use the back of the sheet, indicating the question number you are responding to. Current Social Information 1. Describe your present living arrangements (with whom do you live) and briefly describe these relationships 2. How long have you been married/dating/living together? Describe this relationship (include occupation and age of significant other) 3. How many children do you have? (Name, sex, age) 1
2 4. Are there any significant problems with any of these children? (Describe) 5. Give details of previous relationships/marriages 6. Any history of abuse (emotional, physical, sexual, verbal) in current or previous relationships Family History 7. Describe your childhood and adolescence (include home atmosphere, relationship with parents) 8. Significant life events 9. List mother and father by name, age, occupation 10. List siblings by name and age and describe how you relate to them (past and present) 11. Have any family members been treated for/have emotional problems? Describe Loss History 12. List type and dates of any traumatic losses (death, serious illness/disability, divorce, separation, job loss, retirement, loss of home/relocation) 2
3 13. List type and dates of other changes that resulted in loss (moving, graduation, abuse, change in social status and/or friendships, etc.) Spiritual History 14. Religious affiliation history 15. Describe views on spirituality (God, life after death, meaning of life, connection with something greater than self, etc.) Substance Abuse History 16. Any family history of drug and/or alcohol usage? List and describe 17. Any personal history of drug/alcohol usage? List and describe 18. Describe any change in your pattern of drug/alcohol usage in the past 6 months to 1 year 19. Have you ever had a DUI? No Yes If more than one, how many? Medical History 20. Describe any previous experiences with psychiatrists and/or counselors 3
4 21. Describe any illnesses you have presently and give the name of your attending physician 22. What prescription medications are you taking Educational History 23. Last degree and major or grade completed 24. Where did you go to school (high school, college, vocational, etc.) 25. Describe your school experience (was it positive or problematic, truancy, suspensions, special education, gifted program, etc.) Employment History 26. Present employment status and where (include positive and negative aspects of what is going on at work) 27. Present income 28. If on leave of absence or disability, will you return to present job? Social Activities and Interests 29. List clubs and organizations you belong to 30. What do you do for fun and/or relaxation 4
5 31. Skills/strengths/talents Self-Assessment 32. Check all that apply to you: Depression Low energy Low self-esteem Poor concentration Hopelessness Worthlessness Guilt Sleep disturbance (more/less) Appetite disturbance (more/less) Headaches Thoughts of hurting yourself Thoughts of hurting someone Isolation/social withdrawal Sadness/loss Crying Stress Anxiety Panic Heart pounding/racing Chest pain Trembling/shaking/dizziness Sweating Chills/hot flashes Tingling/numbness Fear of dying Fear of going crazy Fear of being alone Nausea Phobias Obsessions/compulsive behaviors Thoughts racing Easily distracted/can t hold onto an idea Easily agitated/annoyed Excessive behaviors (spending, gambling) Delusions/hallucinations Confusion/not thinking clearly Feeling that you are not real Feeling that things around you are not real Lose track of time Unpleasant thoughts won t go away Anger/frustration Defy rules/authority Blame others Argue Excessive use of drugs and/or alcohol Excessive use of prescription medications Blackouts Physical abuse issues Sexual abuse issues Spousal abuse issues Feeling vulnerable/unsafe Loneliness/emptiness Overwhelmed Afraid Emotionally numb Jealous Over-protective Resentful Frequent illnesses/accidents Hypervigilant/startle easily Restless/constantly busy Feeling lost Spiritual questioning 5
6 Present Situation 33. What/who seems to be placing the most stress on you right now? 34. Are there any legal issues pending? No Yes Describe 35. Are you having any financial problems at this time? 36. What would you like to accomplish in therapy? 37. Is there anything important that we have not asked? Type of Therapy 38. What kind of therapy would you prefer? (You may indicate more than one choice.) Online Chat Therapy Therapy Telephone or WebCam Therapy Face to Face (available in Key West, FL area only) I hearby avow that I am 18 years old or over and will present ID upon request. Client Signature Date If you are under 18 years old, parent/guardian signature is required. Parent/Guardian Name Relationship to Minor Date Signature 6
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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
WOODBRIDGE THERAPY GROUP
Personal History Adult Client s name: Date: Gender: F M Date of birth: Age: Form completed by (if someone other than client): If you need any more space for any of the questions, please use the back of
Mental Health and Suicide Prevention: What Everyone Should Know
Mental Health and Suicide Prevention: What Everyone Should Know OUTLINE Mental Health and Suicide How big is this issue? Mental Illness Depression Schizophrenia Suicide Who is at risk? Warning signs Suicide
ADULT 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
Name: Date of Birth: Address. Why I came for this visit: Who lives with you? Occupation:
BARIATRIC ADULT PSYCHOLOGICAL HISTORY Name: Date of Birth: Address Why I came for this visit: Who lives with you? Occupation: [ ] Live alone [ ] Spouse [ ] Partner Education: [ ] High School [ ] Some College