BIOPSYCHOSOCIAL SCREENING ADULT
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- Joshua Wright
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1 BIOPSYCHOSOCIAL SCREENING ADULT CHART NUMBER: DOB: 1. IDENTIFYING INFORMATION Client Name: Availability: Family Member Name: Availability: Family Member Phone Numbers: Telephone (Day): Telephone (Eve): Can we leave messages at the above listed numbers? 2. RACE/ETHNICITY Caucasian Hispanic Asian/Pacific Islander Black, Not Hispanic American Indian/Alaska Native Other, specify 3. MARITAL STATUS Single Married/Civil Union (year) Separated (year) Divorced (year) Cohabitating/Partnered since (year) Widowed (year) Remarried (year) 4. PRIOR TREATMENT/COUNSELING HISTORY/ AGENCY INVOLVEMENT Have you ever had outpatient counseling before? If yes, please complete below. Reason for Treatment Where When Was it helpful? Have you ever been hospitalized for a psychiatric problem? If yes, please complete below: Reason for hospitalization Where When Was it helpful? Have you ever been hospitalized for a drug or alcohol addiction? (If yes, please complete below): Reason for Treatment Where When Was it helpful? Yes No
2 5. FAMILY HISTORY Name (Please note if deceased) History of Illness in Family Members Sex Age Lives with you Yes No Mother Father Siblings Spouse/ Partner Children Others in the household 6. LEGAL HISTORY 1. Have you been involved in any active legal cases (e.g. custody, divorce, domestic violence complaint, restraining order, arrests, convictions, incarcerations, victim of a violent crime, DWI)? Current Past If yes, briefly state charges, hearing date/trial: 2. Are you presently on probation or parole? If yes, please explain and list name and contact number of parole/probation officer: 7. MILITARY HISTORY Were you ever in the military? If yes, branch: Type of Discharge: Combat experience:
3 8. EDUCATIONAL HISTORY Are you currently pursuing schooling? If yes, where: What is your highest grade completed? When: Where: Did you have any special educational circumstances (e.g. learning disabilities, gifted program, special education classes, etc): 9. EDUCATION AND LEARNING SCREENING Complete table below. 1. Your reading ability: Satisfactory Causes difficulty 2. You learn best by: visual aids hearing (tapes, explanations) Doing Reading 3. Your barriers to learning: None Chronic Pain Language Speech Vision Hearing Emotional limitations Cognitive/Memory Literacy Financial Motivation Cultural Religious Rigid Belief System 4. Your families barriers to learning: N/A Chronic Pain Language Speech Vision Hearing Emotional limitations Cognitive/Memory Literacy Financial Motivation Cultural/Religious Religious Rigid Belief System Other 10. LEISURE/RECREATIONAL HISTORY Describe any special interests or hobbies you may have (art, music, crafts, outdoor activities, church, sports): Has your activity level changed recently? If yes, please explain:
4 11. EMPLOYMENT/VOCATIONAL HISTORY Are you currently employed? Present source of income: Please list employment history for the past 5 years beginning with the most recent, including periods of unemployment: Employer Dates Job Description Are there any special circumstances or concerns related to your employment history (e.g. recently lay off, self-employed, suspended, disabled, injured on the job, retired, etc,)? 12. FINANCIAL ISSUES: Does the client s financial situation affect his/her current condition and treatment? If yes, please explain: 13. NUTRITIONAL SCREENING Weight Height Have you had any recent weight changes? If yes, please explain: Obesity/Weight Gain Recent significant unwanted/unexplained weight loss or appetite change Medical problems requiring special diet Use of diet pills, laxatives, diuretics, forced vomiting Restriction of food intake &/or eating more than planned There is a need for dietary consult at this time Client denies all of the above Please elaborate on any checked boxes:
5 14. HEALTH ASSESSMENT PHYSICIAN INFORMATION Date of last complete physical exam: Date of last visit to physician: New physical required: Please list all current physicians: Physician/Program Name Address Telephone Number Pharmacy Name: Location: Phone: General ALLERGIES: If yes, please list: 15. MEDICATION A) Are you currently taking any prescribed medications? If yes, complete below: Medication Amount Frequency Prescribing Doctor Reason Side effects/ Adverse reaction B) Are you currently taking any over the counter or herbal medications? If yes, complete below: Medication Amount Frequency Reason Side effects/ Adverse reaction c) Do you have any drug allergies? If yes, please specify:
6 16. MEDICAL HOSPITALIZATIONS/ILLNESSES/HEAD TRAUMA Are you currently or have you in the past been diagnosed with any of the following: Infectious disease Frequent falls Hypertension Diabetes Seizure disorder Frequent medical hospitalizations Thyroid problems Speech Difficulties Heart problems Head trauma TIA/Stroke Personality or behavioral change Pain Issues Other If yes, please elaborate: Diagnosis Date Treatment Current Status 17. PHYSICAL FUNCTIONING SCREENING Do you have any physical limitations, or problems with your sight, hearing, or any other senses? Problem Treatment if any If yes, please explain: 18. PHYSICAL PAIN SCREENING Are you currently experiencing any physical pain? If yes, please complete below Location of pain: Treatment, if any: Please rate the degree of your pain:
7 19. DRUG/ALCOHOL HISTORY Complete table below. SUBSTANCE Denies Age of Onset Amount Used Frequency of Use Duration Date of Last Use Method of Use Alcohol Barbiturates Valium/Librium/Xanax, etc. Cocaine/Crack Amphetamines Heroin/Opiates Marijuana PCP/LSD/Mescaline Inhalants Caffeine Nicotine Over-the-counter (Identify) Prescription Drugs (Identify) Other Drugs (Identify) Symptoms of drug/alcohol withdrawal Changes in use and tolerance Shakes Convulsions Hallucinations Blackouts/ memory lapses Other: Pattern of use Continuous Binge Longest length of abstinence: History of relapse Episodic Other: Consequences of use Gambling or other addictive behavior Do you consider yourself to have a substance abuse problem?
8 20. PRIORITIES OF THERAPY Below, please list by priority goals to accomplish in therapy and review with your therapist Priority Focus 1: Priority Focus 2: Priority Focus 3: Client Signature: Date: Clinician Review: Date:
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Addiction Severity Index User Information
Addiction Severity Index User Information The ASI is a multidimentional structured interview introduced by Dr. A. Thomas McLellan in 1980. It is widely used in the United States as a tool for assessing
Client Name: Age: DOB: Date: What brings you to therapy?: How long has the problem been present?
Hope in Healing Counseling and Wellness, LLC Stacy Nunne, MA, LMFT, SEP, RN 600 West 78th Street, Suites 10A-C Mailing Address: PO Box 892 Chanhassen, MN 55317 Chanhassen, MN 55317 Phone: 952-215-5208
Personal Information. Full Name: Address: Primary Phone: Yes No Provider Yes No. Alternate Phone: Yes No Provider Yes No
OFFICE USE ONLY: Date of Intake: ID#: Staff mbr: Personal Information Full Name: Address: _ Last First M.I. Street Address Apartment/Unit # City State Zip Code County Date of Birth: Age: Mobile phone?
Clinical Assessment. Client Name (Last, First, MI) ID # Medicaid # DOB: Age:
Clinical Assessment Client Name (Last, First, MI) ID # Medicaid # DOB: Age: Sex: Ethnic Group: Marital Status: Occupation: Education: Multiaxial Diagnosis Axis I: Clinical Disorders / Other Conditions
Name Age Relationship to patient
Clackamas Pediatric Clinic Oregon Pediatrics Meridian Park 8645 SE Sunnybrook Blvd #200 19260 SW 65 th Ave #275 Clackamas, OR 97015 Tualatin, OR 97062 (503) 659-1694 (503) 691-2519 Oregon Pediatrics Happy
3726 E. Hampton St., Tucson, AZ Phone (520) Fax (520)
3726 E. Hampton St., Tucson, AZ 85716 Phone (520) 319-1109 Fax (520)319-7013 Exodus Community Services Inc. exists for the sole purpose of providing men and women in recovery from addiction with safe,
APPLICATION FORM NAME:
APPLICATION FORM NAME: Application Date: Birthdate: SIN#: Requested Date for Residency: Present Address: Phone #: How long at this address? MSP #: Marital Status: Employment Status: Education: Emergency
CENTER ON DEAFNESS 3444 Dundee Road Northbrook IL / TTY 847/ FAX 847/
CENTER ON DEAFNESS 3444 Dundee Road Northbrook IL 60062 847/559-0110 TTY 847/559-9493 FAX 847/559-8199 APPLICATION FOR ADULT PROGRAMS IDENTIFYING INFORMATION Date: Name: LAST FIRST MIDDLE Address: City:
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:
Program Application for:
Prince of Peace Center P. O. Box 89 502 Darr Ave. Farrell, PA 16121 724-346-5777 www.princeofpeacecenter.org Program Application for: 1 Referred by HOPE FAITH Head of Household Information Gender Male
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