COUPLE COUNSELING ASSESSMENT
|
|
|
- Cora Owen
- 5 years ago
- Views:
Transcription
1 COUPLE COUNSELING ASSESSMENT Date: Client 1 information: Name: Gender: Male Female Age - Date of Birth: Driver s License #: Preferred Please Circle: Self-Pay or Insurance Client 2 information: Name: Gender: Male Female Age - Date of Birth: Driver s License #: Preferred Emergency Contact: Health Insurance: Insurance Company: Policy #: Co-Pay: PCP: Preferred Health Insurance: Insurance Company: Policy #: Co-pay: PCP: Preferred Referral Source: What are your reasons for seeking counseling services at this time? Professional Employer: Status: Highest Degree: Special Ed: Satisfaction: Employer: Status: Highest Degree: Special Ed: Satisfaction: Amy Moreira, LMHC More MH Counseling, LLC. ( ) 1
2 Psychiatric History: Client 1: Name: Diagnosis Hx: Client 2: Name: Diagnosis Hx: Outpt Provider: Frequency: Last Seen: Current Why start/stop: Successful: Unsuccessful: Hx psych meds (name, what for, dose, frequency, duration, compliance, benefits): Outpt Provider: Frequency: Last Seen: Current Why start/stop: Successful: Unsuccessful: Hx psych meds (name, what for, dose, frequency, duration, compliance, benefits): Provider: Last Seen: Provider: Last Seen: Mental Health History Inpatient Hx: Reason: Suicide Attempt Hx: Self-injury: Family Hx suicide: Family MH hx: Trauma Hx: Violence Hx: Developmental Hx: Recent life changes/stress: Inpatient Hx: Reason: Suicide Attempt Hx: Self Injury: Family hx suicide: Family MH hx: Trauma Hx: Violence Hx: Developmental Hx: Recent life changes/stress: Amy Moreira, LMHC More MH Counseling, LLC. ( ) 2
3 Hours of sleep: Sleep issues? Hours of Exercise: Appetite Disturbances? Hours of sleep: Sleep issues? Hours of Exercise: Appetite Disturbances? Substance Abuse Hx: (How much, how often, last use - onset) Alcohol: Marijuana: Heroin: Cocaine: Detox hx: Disruption in functioning: Family Hx: Alcohol: Marijuana: Heroin: Cocaine: Detox hx: Disruption in functioning: Family Hx: Legal Status Incarceration Hx (parole, probation) Sexual offense hx: Immigration Issues: Goals/Issues: Incarceration Hx: (parole, probation) Sexual offense hx: Immigration Issues: Goals/Issues Social Relationships/Support Social Interests: Social supports: Religious activities: Family activities: Issues: Family/siblings/birthplace: Social Interests: Social Supports: Religious activities: Family activities: Issues: Family/siblings/birthplace: Amy Moreira, LMHC More MH Counseling, LLC. ( ) 3
4 Relationship Status Relationship Status: Single Relationship Engaged Married Separated Divorced Length of relationship: Biological Children: Living in household: Children: Quality of relationship: Custody Issues: Parenting Issues: Stressors: Children: Quality of relationship: Custody Issues: Parenting Issues: Stressors: Relationship strengths: Activities Together: Desired activities: Relationship weakness: Relationship strengths: Activities Together: Desired activities: Relationship weakness: Disagreements: Disagreements: Domestic violence: Domestic violence: Infidelity/mistrust: Social issues: Blame/resentment: Commitment issues: Changes in affection/intimacy: Infidelity/mistrust: Social issues: Blame/resentment: Commitment issues: Changes in affection/intimacy: Amy Moreira, LMHC More MH Counseling, LLC. ( ) 4
5 Disagreements: Disagreements: Separation/threats: Separation/threats: Communication issues: Communication issues: Have you tried anything to resolve? Have you tried anything to resolve? Amy Moreira, LMHC More MH Counseling, LLC. ( ) 5
6 Client 1: Name: Circle if it pertains to your reason or seeking mental health counseling at this time: Memory Disruptive Behavior Drug Dependence Unhappiness Social Isolation Shyness Financial Problems Self-Injury Education Legal Matters Drug Use Sleep Disturbance Insomnia Indecisive Grief Anger Troublesome Thoughts Racism Empowerment Loneliness Stress Problems with Anger Health Problems Nightmares Parenting Worry Problems with Authority Weight Control Chronic Pain Divorce/Separate Attitude Fatigue/Tiredness Suspiciousness Loneliness PTSD Fears Sexual Problems Low Self-Esteem Education Self-Control Guilt Violent disagreements Mood Swings Body Image Social Isolation Work Lifestyle disagreements Reproductive Prob Relationship Assertiveness Family Sadness/Depression Suicidal Thoughts Life Transitions Impulsivity Racism Sexual Dysfunction Family Relations Incarceration Blending Family Infidelity Physical Intimacy Domestic Violence Trust Issues Blended family Inferiority Questioning sexual Emotional Non-traditional Social Media orientation Communication relationship Housing Parenting arguments Frequent break-up Sleeping on couch Issues Verbal Communication Behavior Acting strangely. Attempting weight loss. Seeking attention. Arguing with others. Dreading work. Rejecting affection. Not offering affection. Not listening to others. Not staying on track. Difficulty waiting turn. Checking/counting (ritual). Exercising excessively Fidgeting a lot. Hoarding objects. Initiating fights. Losing things. Showing inflexibility. Being perfectionist. Taking risks. Startling easily. Fears Fearing abandonment. Fearing crowds. Fearing dying. Fearing embarrassment. Fearing gaining weight. Fearing losing loved ones. Feelings Feeling agitated. Feeling angry. Feeling anxious. Feeling self-conscious. Feeling cocky. Feeling depressed. Feeling indecisive. Feeling confused. Feeling hopeless/helpless. Lack of self-worth. Feeling moody. Feeling unstable. Amy Moreira, LMHC More MH Counseling, LLC. ( ) 6
7 Interpersonal Having poor social supports. Feeling easily influenced. Lacking friends. Thoughts Forgetting things. Having delusions. Having erratic thoughts. Having intrusive thoughts. Having paranoia. Having rapid thoughts. Hearing voices not there. Lacking focus. Lacking motivation. Lacking organization. Obsessing over symmetry Seeing things not there. Thinking of death. Worrying about health. Physical Symptoms Feeling chills. Feeling muscle tension. Feeling nauseated. Feeling restless. Sleepy in daytime. Feeling too energetic. Feeling too tired. Gaining appetite. Gaining weight. Needing little sleep. Sleeping too much. Sleeping too little. Sweating. Rapid breathing. Panic attacks. Clinical Impression 1: Clinical Impression 2: Additional Information: Clinician Signature: Date: GOALS Amy Moreira, LMHC More MH Counseling, LLC. ( ) 7
8 Client 2: Name: Circle if it pertains to your reason or seeking mental health counseling at this time: Memory Disruptive Behavior Drug Dependence Unhappiness Social Isolation Shyness Financial Problems Self-Injury Education Legal Matters Drug Use Sleep Disturbance Insomnia Indecisive Grief Anger Troublesome Thoughts Racism Empowerment Loneliness Stress Problems with Anger Health Problems Nightmares Parenting Worry Problems with Authority Weight Control Chronic Pain Divorce/Separate Attitude Fatigue/Tiredness Suspiciousness Loneliness PTSD Fears Sexual Problems Low Self-Esteem Education Self-Control Guilt Violent disagreements Mood Swings Body Image Social Isolation Work Lifestyle disagreements Reproductive Prob Relationship Assertiveness Family Sadness/Depression Suicidal Thoughts Life Transitions Impulsivity Racism Sexual Dysfunction Family Relations Incarceration Blending Family Infidelity Physical Intimacy Domestic Violence Trust Issues Blended family Inferiority Questioning sexual Emotional Non-traditional Social Media orientation Communication relationship Housing Parenting arguments Frequent break-up Sleeping on couch Issues Verbal Communication Behavior Acting strangely. Attempting weight loss. Seeking attention. Arguing with others. Dreading work. Rejecting affection. Not offering affection. Not listening to others. Not staying on track. Difficulty waiting turn. Checking/counting (ritual). Exercising excessively Fidgeting a lot. Hoarding objects. Initiating fights. Losing things. Showing inflexibility. Being perfectionist. Taking risks. Startling easily. Fears Fearing abandonment. Fearing crowds. Fearing dying. Fearing embarrassment. Fearing gaining weight. Fearing losing loved ones. Feelings Feeling agitated. Feeling angry. Feeling anxious. Feeling self-conscious. Feeling cocky. Feeling depressed. Feeling indecisive. Feeling confused. Feeling hopeless/helpless. Lack of self-worth. Feeling moody. Feeling unstable. Amy Moreira, LMHC More MH Counseling, LLC. ( ) 8
9 Interpersonal Having poor social supports. Feeling easily influenced. Lacking friends. Thoughts Forgetting things. Having delusions. Having erratic thoughts. Having intrusive thoughts. Having paranoia. Having rapid thoughts. Hearing voices not there. Lacking focus. Lacking motivation. Lacking organization. Obsessing over symmetry Seeing things not there. Thinking of death. Worrying about health. Physical Symptoms Feeling chills. Feeling muscle tension. Feeling nauseated. Feeling restless. Sleepy in daytime. Feeling too energetic. Feeling too tired. Gaining appetite. Gaining weight. Needing little sleep. Sleeping too much. Sleeping too little. Sweating. Rapid breathing. Panic attacks. Clinical Impression 1: Clinical Impression 2: Additional Information: Clinician Signature: Date: GOALS Amy Moreira, LMHC More MH Counseling, LLC. ( ) 9
10 Name: When We Are Not Getting Along: My Feelings, Thoughts, and Behaviors Check all the statements that reflect the way you feel or what you do when you are your partner are fighting or not getting along. What I Do I criticize I attack I blame I defend myself I analyze I overthink I bring up past events I get quiet I shutdown I become cold I say hurtful things I clam up I withdraw I avoid conflict I leave Verbally aggressive Physically aggressive What My Partner Does.. Criticizes me Attacks me Blames me Defends himself Analyzes Overthinks Bring up past events Gets quiet Shuts down Becomes cold Say hurtful things Clams up Withdraws Avoids conflict Leaves Verbally aggressive Physically aggressive Check Left, what You feel.. Right, what your partner feels. Scared Afraid Hurt Vulnerable Worried or nervous Disappointed Let down Sad Alone or lonely Hopeless Down or depressed Empty Disconnected Isolated Rejected Abandoned Misunderstood Overwhelmed Frustrated Angry Vindictive Self-protective Guarded Clingy Too emotional Unable to self-calm Blank Number Unable to communicate Confused Unfocused Judged Uncared for Inadequate Guilty Failure Attacked Dismissed Unlovable Invalidated Controlled Intimidated Put down Analyzed Dismissed Unattractive Insignificant Amy Moreira, LMHC More MH Counseling, LLC. ( ) 10
11 Name: When We Are Not Getting Along: My Feelings, Thoughts, and Behaviors Check all the statements that reflect the way you feel or what you do when you are your partner are fighting or not getting along. What I Do I criticize I attack I blame I defend myself I analyze I overthink I bring up past events I get quiet I shutdown I become cold I say hurtful things I clam up I withdraw I avoid conflict I leave Verbally aggressive Physically aggressive What My Partner Does.. Criticizes me Attacks me Blames me Defends himself Analyzes Overthinks Bring up past events Gets quiet Shuts down Becomes cold Say hurtful things Clams up Withdraws Avoids conflict Leaves Verbally aggressive Physically aggressive Check Left, what You feel.. Right, what your partner feels. Scared Afraid Hurt Vulnerable Worried or nervous Disappointed Let down Sad Alone or lonely Hopeless Down or depressed Empty Disconnected Isolated Rejected Abandoned Misunderstood Overwhelmed Frustrated Angry Vindictive Self-protective Guarded Clingy Too emotional Unable to self-calm Blank Number Unable to communicate Confused Unfocused Judged Uncared for Inadequate Guilty Failure Attacked Dismissed Unlovable Invalidated Controlled Intimidated Put down Analyzed Dismissed Unattractive Insignificant Amy Moreira, LMHC More MH Counseling, LLC. ( ) 11
WHEN WE RE NOT GETTING ALONG FEELINGS, THOUGHTS AND BEHAVIORS
WHEN WE RE NOT GETTING ALONG FEELINGS, THOUGHTS AND BEHAVIORS Name Date INSTRUCTIONS Check all the statements that reflect the way you feel or what you do when you and your spouse are fighting or not getting
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
Client Intake Form. First Name: M.I.: Last Name: Birthdate: Gender: Age: Address: City: State: Zip:
Client Intake Form First Name: M.I.: Last Name: Birthdate: Gender: Age: Address: City: State: Zip: Tel: Home: Okay to leave message? (Circle one) Yes No Tel: Work: Ext Okay to leave message? (Circle one)
Do not write below this line DSM IV Code: Primary Secondary. Clinical Information
New Client Registration Today s date Name Age Sex Address Social security # Date of birth Home phone May I call you at this number? y / n Leave a message? y / n Other numbers at which I can call you Can
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
FMS 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:
CLIENT 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
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.
MINOR 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
Patient 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:
Anxiety Depression Sleep problems Thoughts of suicide. Panic Unusual thoughts Anger outbursts Changes in weight
Client Information Name: Biographical Information Please complete this form, which will provide information useful in treatment. If you are not the patient (for example, if you are giving information about
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:
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
Psychiatric 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
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?
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
COUNSELING ASSESSMENT REFERRAL AND BACKGROUND INFORMATION (Adult Form) cell telephones/fax #s/ addresses: (Spouse): (Emergency Contact):
Joanna C. Ioannides, LCSW *Lowry Counseling, LLC *7581 E. Academy Blvd. Ste 209 * Denver, CO 80230*Ph. (720)319-7319 Fax (303)379-4607* counseldenver@aol.com* COUNSELING ASSESSMENT REFERRAL AND BACKGROUND
International Childbirth Education Association. Postpartum Doula Program
International Childbirth Education Association Postpartum Doula Program Part 3: Postpartum Emotions Objective: Describe the range of possible postpartum emotions. List two factors that affect postpartum
Chapter 3 Self-Esteem and Mental Health
Self-Esteem and Mental Health How frequently do you engage in the following behaviors? SCORING: 1 = never 2 = occasionally 3 = most of the time 4 = all of the time 1. I praise myself when I do a good job.
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
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
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?
A NEW MOTHER S. emotions. Your guide to understanding maternal mental health
A NEW MOTHER S emotions Your guide to understanding maternal mental health It is not your fault It is treatable Understanding Maternal Mental Health Life with a new baby is not always easy and the adjustment
Very much. N/A No A little Pretty much. Making careless mistakes
Weiss Symptom Record The following is a list of different kind of problems. Everyone has some of these difficulties at some time. We want to know if any of these things are causing more difficulty than
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
Sonja 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
MERLE 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
Other significant mental health complaints
Other significant mental health complaints 2 Session outline Introduction to other significant mental health complaints Assessment of other significant mental health complaints Management of other significant
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
PSYCHIATRIC 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
CHECKLIST OF CONCERNS AND HISTORY FORM
CHECKLIST OF CONCERNS AND HISTORY FORM Name: Date: Please mark any items that apply to you. PROBLEM AREAS--CAREER, SCHOOL Career concerns, goals, and choices Unemployment Job stress School problems Learning
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:
Adult Service Application
Adult Service Application Client # Client Name: Date: _ Are you your own legal guardian? Yes No If no, who is your legal guardian? Former name/maiden name: _ Sex: Male Female Sexual Orientation: _ SSN:
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:
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)
ADULT QUESTIONNAIRE. Date of Birth: Briefly describe the history and development of this issue from onset to present.
ADULT QUESTIONNAIRE Name: Address: Preferred phone number to reach you: Is it okay to leave a message? Yes No (Please check one) Date of Birth: Reason(s) for seeking treatment at this time? Briefly describe
1811 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
Warning Signs of Mental Illness in Children/Adolescents. Beth Confer, MA, LPC Director, Community Relations Clarity Child Guidance Center
Warning Signs of Mental Illness in Children/Adolescents Beth Confer, MA, LPC Director, Community Relations Clarity Child Guidance Center Identify At least 5 warning signs of mental illness in children
Demographic 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
Child & 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
Child s name: Nickname: Date of Birth: / / Sex: Male Female SSN: Today s date: / / Parent s Name #1: Home phone: ( ) Cell: ( )
Please fill out the entire form, answering the questions as they pertain to your child or teen. Leave blank any that are unclear or that you want additional clarification on. Thank you. General Information:
Healing the Traumatized Family. Sean Smith MA, M.Ed., LPC, CAADC
Healing the Traumatized Family Sean Smith MA, M.Ed., LPC, CAADC Brené Brown Of all the things trauma takes away from us, the worst is our willingness, or even our ability, to be vulnerable. There's a reclaiming
Preferred Name (s): Local Address: City: State: Zip: Permanent Address: City: State: Zip: Years of Education: Occupation: Gender: M F
Today Date: Client Name(s) : Psychological Consultants Northgate Center 1210 ½ -7 th Street NW, Suite 216 Rochester, MN 55901 www.psychologicalconsultants1.com Office: (507) 252-9292 Fax: (507) 252-9203
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:
DEPRESSION. There are a couple of kinds, or forms. The most common are major depression and dysthymic disorder.
DEPRESSION OBJECTIVES: At the end of this class, you will be able to: 1.list and describe several kinds of depression, 2.discuss the signs of depression, and 3.relate the treatment of depression. INTRODUCTION
Depression Fact Sheet
Depression Fact Sheet Please feel free to alter and use this fact sheet to spread awareness of depression, its causes and symptoms, and what can be done. What is Depression? Depression is an illness that
WORD WALL. Write 3-5 sentences using as many words as you can from the list below.
WORD WALL Write 3-5 sentences using as many words as you can from the list below. Suicide Phobia Bipolar Obsessive compulsive disorder(ocd) Anxiety Depression Mood Post traumatic stress disorder (PTSD)
Effects of Traumatic Experiences
Effects of Traumatic Experiences A National Center for PTSD Fact Sheet By Eve B. Carlson, Ph.D. and Josef Ruzek, Ph.D When people find themselves suddenly in danger, sometimes they are overcome with feelings
MINDFUL 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:
Client 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
DVI Pre - Post Instructions Drinking Drugs Section 1 True True False False
DVI Pre - Post Instructions You are completing this inventory to give the staff information that will help them understand your situation and needs. The statements are numbered. Each statement must be
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
Psychological First Aid: Overview Helping Others in Times of Stress
Welcome Psychological First Aid: Overview Helping Others in Times of Stress February 2012 Instructor Anita Laffey, LCSW Licensed Clinical Social Worker, retired Red Cross disaster volunteer since 2005
Intake Information Form
Intake Information Form First Name: MI: Last : Birth date: / / Referred by: Insurance / other: Address: City:, Zip: living with: phone: (H): (W): (C): Email: Occupation: FT / PT since: Student: yes / no
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
GOT ANGER? PRACTICAL ANGER MANAGEMENT TECHNIQUES FOR DAILY LIVING
GOT ANGER? PRACTICAL ANGER MANAGEMENT TECHNIQUES FOR DAILY LIVING BY Mark S. Miller, LMFT Director, Emerge From Anger Kendall Evans, LMFT Senior Staff Member, Emerge From Anger Patricia Patton, Ph.D. -
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
The Seed Planter Coaching & Counseling, PLLC Nanette Floyd Patterson, MA, LPC INTAKE FORM
Name Date Date of Birth Relationship Status Age Home Number # of Dependents Gender (Male/Female) Guardian s Name Telephone Mobile Phone Is it ok to leave a message at this number? (Yes/No) Work Phone Is
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
Initial Evaluation Template
Demographic Information (Please complete all questions on this form) Member Name: Date: Name: Address: Phone (Home): Phone (Work): Date of Birth: Social Security #: Guardianship (for children and adults
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
October 8, 2013 Teens and Stress Presented by: Susan Sakamoto, MSW, MHP, EMMHS, CMH
October 8, 2013 Teens and Stress Presented by: Susan Sakamoto, MSW, MHP, EMMHS, CMH susans@youtheastsideservices.org A lifeline for kids and families AGENDA Who Is YES? Let s Talk Stress o What is it?
Name:, Sex:, Age: Ethnicity, Race. Date of Birth:, address: Address:, City: State:, County,, Zip: Telephone numbers: Home: ( ),Work: ( )
Adult Patient Information Name:, Sex:, Age: Ethnicity, Race Date of Birth:, Email address: Address:, City: State:, County,, Zip: Telephone numbers: Home: ( ),Work: ( ) Cell: ( ) Referral by: Person to
The ABC s of Trauma- Informed Care
The ABC s of Trauma- Informed Care AGENDA What do we mean by trauma? How does trauma affect people? What can we learn from listening to the voices of people who have experienced trauma? Why is understanding
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
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?
Charles Schroeder EMS Program Manager NM EMS Bureau
Charles Schroeder EMS Program Manager NM EMS Bureau Objectives Understand the nature of stress, emotional and psychological distress Understand how it affects people and why Help you to recognize the stressors
Mr. Stanley Kuna High School
Mr. Stanley Kuna High School Stress What is Stress? Stress is - The mental, emotional, and physiological response of the body to any situation that is new, threatening, frightening, or exciting. Stress
Synergy Conference October 1, 2014 Amy S Hill, LPCC-S. LICDC-CS, Associate Director Delaware-Morrow Mental Health & Recovery Services Board 1
Synergy Conference October 1, 2014 Amy S Hill, LPCC-S. LICDC-CS, Associate Director Delaware-Morrow Mental Health & Recovery Services Board 1 1 in 5 young people have one or more mental, emotional, or
Chapter 20 Psychosocial Nursing of the Physically Ill Client Psychosocial Assessment Interactive process that involves gathering data and evaluating
Chapter 20 Psychosocial Nursing of the Physically Ill Client Psychosocial Assessment Interactive process that involves gathering data and evaluating the past and current level of functioning of the client
Mental Health First Aid at a Glance
Mental Health First Aid at a Glance Candice M. Haines, LCPC Program Supervisor Mental Health First Aid Instructor Pilsen Wellness Center chaines@pilsenmh.org Overview Address myths vs facts Warning signs
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
James M. Harper, Ph.D. Family Therapy Programs BYU Comprehensive Clinic
James M. Harper, Ph.D. Family Therapy Programs BYU Comprehensive Clinic National Institute of Mental Health estimates 26% of adults experience a mental illness in a given year-57.7 million Adults Suffering
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,
Intake Questionnaire
1100 Jorie Blvd. Suite 132 Oak Brook, IL 60523 630-522-3124 Intake Questionnaire Please be as detailed as you can within your level of comfort. For fields that either do not apply to you, or that you do
Understanding Your Own Grief Journey. Information for Teens
Understanding Your Own Grief Journey Information for Teens Grief is a natural response to love and loss. People who are grieving experience a variety of feelings, sometimes in succession, sometimes at
UW MEDICINE PATIENT EDUCATION. Baby Blues and More. Postpartum mood disorders DRAFT. Emotional Changes After Giving Birth
UW MEDICINE PATIENT EDUCATION Baby Blues and More Postpartum mood disorders Some new mothers have baby blues or more serious postpartum mood disorders. This chapter gives ideas for things you can do to
Name of Client: Former or Maiden name: Date of Birth: Age: SSN# Gender: Male Female
Adult Intake Forms LAKE COUNTRY ASSOCIATES, INC. 515 Bridge Street East, Park Rapids, MN 56470 ph: 218-366-9229 1426 Bemidji Ave NW, Ste 1 Bemidji, MN 56601 ph: 218-444-2233 Fax: 218-237-2520 11 Main Street
Members Can Do. What Community. From the National Institute of Mental Health. Helping Children and Adolescents Cope with Violence and Disasters
Helping Children and Adolescents Cope with Violence and Disasters For Teachers, Clergy, and Other Adults in the Community What Community Members Can Do From the National Institute of Mental Health Violence
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
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,
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
A-Z of Mental Health Problems
Mental health problems can cover a broad range of disorders, but the common characteristic is that they all affect the affected person s personality, thought processes or social interactions. They can
12. I can be easily annoyed and angered while driving. 13. I am concerned about my drug use. 14. I have used my cell phone while driving.
OK DRI-2 Instructions We realize this is a difficult time for you. Nevertheless, we need more information so we can better understand your situation. All questions in this questionnaire should be answered.
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
SCL-90. Backaches 0 (T) In this case, the respondent experienced backaches a little bit (1). Please proceed with the questionnaire.
4-79 Name Date SCL-90 Below is a list of problems and complaints that people sometimes have. Please read each one carefully. After you have done so, select one of the numbered descriptors that best describes
De-stress from Deployment: Handling Stress after Deployment
De-stress from Deployment: Handling Stress after Deployment Please download the De-Stress from Deployment: Handling Stress after Deployment Worksheet and Handouts before beginning this class. 1 There are
UW MEDICINE PATIENT EDUCATION. Baby Blues and More DRAFT. Knowing About This in Advance Can Help
UW MEDICINE PATIENT EDUCATION Baby Blues and More Recognizing and coping with postpartum mood disorders Some women have baby blues or more serious postpartum mood disorders. It helps to know about these
SAQ-Adult Probation III
SAQ-Adult Probation III Instructions The statements in this booklet are numbered. Match the number of the statement with the number on your answer sheet. All statements must be answered. Your records may
SAQ. Complete the information at the top of your answer sheet. Then, starting with question one, answer every question.
SAQ Instructions The statements in this test are numbered. Do not skip any questions. Do not lie or give false information. This test measures truthfulness. In addition, your available records may be used
An Introduction to Crisis Intervention. Presented by Edgar K. Wiggins, MHS Executive Director, Baltimore Crisis Response, Inc.
An Introduction to Crisis Intervention Presented by Edgar K. Wiggins, MHS Executive Director, Baltimore Crisis Response, Inc. Why is this training important? Brief History of Crisis Intervention Cocoanut
Substance Abuse Affects Families
Substance Abuse Affects Families Help Is Available Facts on Substance Abuse One of the most important signs of substance use disorder is using drugs or alcohol even when using them causes severe physical,
Intake 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
MO DRI-2 Instructions We realize this is a difficult time for you. Nevertheless, we need more information so we can better understand your situation.
MO DRI-2 Instructions We realize this is a difficult time for you. Nevertheless, we need more information so we can better understand your situation. All questions in this questionnaire should be answered.
COUPLE & FAMILY INSTITUTE OF TRI-CITIES AMEN ADULT GENERAL SYMPTOM CHECKLIST
COUPLE & FAMILY INSTITUTE OF TRI-CITIES AMEN ADULT GENERAL SYMPTOM CHECKLIST Please rate yourself on each symptom listed below. Please use the following scale: 0--------------------------1---------------------------2--------------------------3--------------------------4
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
Responding to Traumatic Reactions in Children and Adolescents. Steve Minick Vice President of Programs
Responding to Traumatic Reactions in Children and Adolescents Steve Minick Vice President of Programs stevem@fsnwpa.org 814 866-4500 TF-CBT at Family Services Trauma Types Served 760 Documented Physical
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
Family Life Counseling, P.C.
Family Life Counseling, P.C. For office use only 6240 S. Main Street, #265 DX: Aurora, CO 80016 GAF: Current Past Phone: (720) 274-5270 Fax: (720) 274-5267 CPT: Auth: Intake Information Patient Name: Last
NORTHLAKE YOUTH ACADEMY Psychiatric Residential Treatment Facility Hwy. 190 Mandeville, Louisiana Phone: Fax:
NORTHLAKE YOUTH ACADEMY Psychiatric Residential Treatment Facility 23515 Hwy. 190 Mandeville, Louisiana 70470 Phone: 985-626-6534 Fax: 985-626-6398 Completed by: Date: Resident s Name: Resident s Date