ADULT INFORMATION FORM

Transcription

1 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: Today s Date: SS #: Gender: M F Birth date: Age: Address: City: Zip: Phone: (home): (mobile): Address: Emergency contact: Telephone number: Relationship: How did you hear about Sauder Psychology? Primary reason(s) for seeking services at this time: Family Information Adult Household Living Living with you Name and Relationship Age Yes No Yes No Partner Status (more than one answer may apply) Single Living with Partner (unmarried) Separated Divorce in process Legally Married Divorced Widowed Length of time in current relationship (if applicable): Assessment of current relationship (if applicable): Good Fair Poor Parental Information Parents legally married Parents ever separated Mother remarried: Number of times : Father remarried: Number of times: Parents ever divorced Special circumstances (e.g., raised by person other than parents, information about spouse/children not living with you, etc.): Development Are there special, unusual, or traumatic circumstances that affected your development? Yes No If Yes, please describe: Has there been a history of child abuse: Yes No

2 If yes, which type(s)? Sexual Physical Verbal Emotional Other childhood issues: Neglect Inadequate nutrition Other Comments regarding childhood development: Which of the following best describes the family in which you grew up? Warm and accepting Average Hostile / fighting Which of the following best describes the way in which your family raised you? Allowed me to be Attempted to very independent Average control me What was your mother s occupation when you were a child? What was your father s occupation when you were a child? Social Relationships Check how you generally get along with other people: (check all that apply) Affectionate Aggressive Avoidant Fight/argue often Follower Friendly Leader Outgoing Shy/withdrawn Submissive What is your sexual orientation? Comments: Are you experiencing a sexual problem? Yes No Is your house troubled by domestic violence? Yes No Cultural/ Ethnic To which cultural or ethnic group do you belong? Are you experiencing any problems due to cultural or ethnic issues? Yes No Other cultural/ethnic information: Spiritual/ Religious How important to you are spiritual matters? Not Little Moderate Much Are you affiliated with a spiritual or religious group? Yes No Would you like your spiritual/religious beliefs incorporated in this counseling? Yes No Legal Current Status Are you involved in any active cases (traffic, civil, criminal)? Yes No Are you presently on probation or parole? Yes No Past History Traffic violations: Yes No DWI, DUI, etc.: Yes No Criminal involvement: Yes No Civil involvement: Yes No

3 Education Years of education completed: Degree held: Currently enrolled in school? Yes No Other training: Special circumstances (e.g., learning disabilities, gifted): Begin with most recent job, list job history: Employment Employer Dates Title Reason left job How often miss work? Currently: FT PT Temp Laid-off Disabled Retired Social Security Student Other (describe): Military Military experience? Yes No Combat experience: Yes No Describe special areas of interest or hobbies: Leisure/Recreational Activity How often now? How often in the past? List any current health concerns: List any recent health or physical changes: Nutrition Medical/Physical Health Meal How often Typical foods eaten Typical amount eaten (times per week) Breakfast /week No Low Med High Lunch /week No Low Med High Dinner /week No Low Med High Snacks /week No Low Med High Comments: Current prescribed medications Dose Dates Purpose Side effects Current over-the-counter meds Dose Dates Purpose Side effects Prescribing Physician s Name: Phone Number:

4 Date Reason Results Last physical exam Last doctor s visit Last dental exam Most recent surgery Family history of medical problems: Please check if there have been any recent changes in the following: Sleep patterns Eating patterns Energy level General disposition Weight Nervousness/tension Chemical Use History Please Circle the Substances you Currently Use: Alcohol PCP/LSD/Mescaline Barbiturates Meth Valium/Librium Inhalants Cocaine/Crack Caffeine Heroin/Opiates Nicotine Marijuana Other drugs(list): Describe when and where you typically use substances: Describe any changes in your use patterns: Please Circle the Substances you Have Used in the Past: Alcohol Barbiturates Valium/Librium Cocaine/Crack Heroin/Opiates Marijuana PCP/LSD/Mescaline Meth Inhalants Caffeine Nicotine Other drugs: Does/Has someone in your family present/past have/had a problem with drugs or alcohol? Yes No Have you had adverse reactions or overdose to drugs or alcohol? Yes No Have drugs or alcohol created a problem for your job? Yes No Have drugs or alcohol created a problem for your family? Yes No Counseling/Prior Treatment History Information about client (past and present): Your reaction Yes No When Where to overall experience Counseling/Psychiatric Suicidal thoughts Suicide attempts Drug/alcohol treatment Hospitalizations Involvement with Self-help groups (e.g., AA, Al-Anon, NA, Overeaters Anonymous) Information about family/significant others (past and present): Their reaction Yes No When Where to overall experience Suicidal thoughts Suicide attempts Drug/alcohol treatment

5 Please check behaviors and symptoms that occur to you more often than you would like them to take place: Aggression Elevated mood Phobias/fears Alcohol dependence Fatigue Recurring thoughts Anger Gambling Sexual addiction Antisocial behavior Hallucinations Sexual difficulties Anxiety Heart palpitations Sick often Avoiding people High blood pressure Sleeping problems Chest pain Hopelessness Speech problems Cyber addiction Impulsivity Suicidal thoughts Depression Irritability Thoughts disorganized Disorientation Judgment errors Trembling Distractibility Loneliness Withdrawing Dizziness Memory impairment Worrying Drug dependence Mood shifts Other (specify): Eating disorder Panic attacks Briefly discuss how the above symptoms impair your ability to function effectively (socially, emotionally, occupationally, and physically): Any additional information that would assist in understanding your concerns or problems: What are your goals for therapy? Do you feel suicidal at this time? Yes No

6 DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure Adult Name: Age: Sex: Male Female Date: If this questionnaire is completed by an informant, what is your relationship with the individual? In a typical week, approximately how much time do you spend with the individual? hours/week Instructions: The questions below ask about things that might have bothered you. For each question, circle the number that best describes how much (or how often) you have been bothered by each problem during the past TWO (2) WEEKS. During the past TWO (2) WEEKS, how much (or how often) have you been bothered by the following problems? None Not at all Slight Rare, less than a day or two Mild Several days Moderate More than half the days I. 1. Little interest or pleasure in doing things? 2. Feeling down, depressed, or hopeless? II. 3. Feeling more irritated, grouchy, or angry than usual? III. 4. Sleeping less than usual, but still have a lot of energy? Severe Nearly every day Highest Domain Score (clinician) 5. Starting lots more projects than usual or doing more risky things than usual? IV. 6. Feeling nervous, anxious, frightened, worried, or on edge? 7. Feeling panic or being frightened? 8. Avoiding situations that make you anxious? V. 9. Unexplained aches and pains (e.g., head, back, joints, abdomen, legs)? 10. Feeling that your illnesses are not being taken seriously enough? VI. 11. Thoughts of actually hurting yourself? VII. 12. Hearing things other people couldn t hear, such as voices even when no one was around? 13. Feeling that someone could hear your thoughts, or that you could hear what another person was thinking? VIII. 14. Problems with sleep that affected your sleep quality over all? IX. 15. Problems with memory (e.g., learning new information) or with location (e.g., finding your way home)? X. 16. Unpleasant thoughts, urges, or images that repeatedly enter your mind? XI. 17. Feeling driven to perform certain behaviors or mental acts over and over again? 18. Feeling detached or distant from yourself, your body, your physical surroundings, or your memories? XII. 19. Not knowing who you really are or what you want out of life? 20. Not feeling close to other people or enjoying your relationships with them? XIII. 21. Drinking at least 4 drinks of any kind of alcohol in a single day? 22. Smoking any cigarettes, a cigar, or pipe, or using snuff or chewing tobacco? 23. Using any of the following medicines ON YOUR OWN, that is, without a doctor s prescription, in greater amounts or longer than prescribed [e.g., painkillers (like Vicodin), stimulants (like Ritalin or Adderall), sedatives or tranquilizers (like sleeping pills or Valium), or drugs like marijuana, cocaine or crack, club drugs (like ecstasy), hallucinogens (like LSD), heroin, inhalants or solvents (like glue), or methamphetamine (like speed)]? Copyright 2013 American Psychiatric Association. All Rights Reserved. This material can be reproduced without permission by researchers and by clinicians for use with their patients.