Gishela Satarino, MA, LPC-S 6750 Hillcrest Plaza Drive, #203 Dallas, TX 75230 214-280-3664 History Form for Counseling Services Client s Name: Age: Today s Date: / / Client s Sex: Client s Birthplace: Birthdate: / / Address: City: State: Zip/Postal Code: How long at this address? Education: Name of Employer: Work Phone: May I contact you at this work #? Yes No May I leave a message? Yes No Type of Work: Home Phone: May I contact you at this home #? Yes No May I leave a message? Yes No E-mail address: Cell Phone: May I contact you on this cell phone? Yes No May I leave a message? Yes No Please describe the problems for which help is needed at this time. Has the client ever received mental health treatment (including psychotherapy or prescribed psychiatric medication)? No Yes If yes, please complete the following history of psychiatric/psychological treatment (including psychiatric medication prescribed by a non-psychiatrist physician such as a pediatrician).! 1
Name of Organization/ Professional Date & Duration Address Psychiatric History: Has this client ever taken psychiatric medications? No If no, please go to page 4 and continue with therapy history. Yes. If yes, please complete page 3. Drug Name Dose Side Effects Results! 2
Drug Name Dose Side Effects Drug Name Dose Side Effects! 3
Therapy History: Has this client ever received mental health related therapy? No Yes Don t know If no, please go to page 5. If yes, please complete the following: Please use the following chart(s) to describe all therapies this client has received previously. Space is provided, if necessary for up to 4 therapy descriptions. Type of Therapy How Often Adverse Reactions Therapy Therapy Type of Therapy How Often Adverse Reactions Therapy Therapy! 4
Current Family Stressors: Please include things such as recent death in family, caregiver relationship problems, financial problems, serious medical or psychiatric illness, job problems or unemployment, domestic violence Trauma: Please include any traumas impacting the client such as witnessing domestic or other violence, sexual, physical or emotional abuse of this client, neglect, or accidents where this client or someone was badly hurt Medical History of Client: Does this client currently take any medications for a medical illness? No Yes If yes, please describe: Family Psychiatric History: (Please note any that apply: Major Depression, Bipolar Disorder, Anxiety Disorders, Schizophrenia, Tic Disorders, Substance/Alcohol Abuse, Suicide Attempts, Eating Disorders, or other Psychiatric problems) Have any of this client s biological relatives had psychiatric problems? No Yes Don t know If yes, please specify the problem next to the relative. Mother Father Brother Sister Grandmother Grandfather Aunt Uncle Outside of biological relatives, are there any other people with whom the client has significant contact who have psychiatric problems? No Yes Don t know If yes, please specify the contact(s) and describe the problem(s), including treatment: Who can I thank for referring you to me?! 5
Name: Address: Signature of person completing form Signature of person completing form Date Date! 6
For Minors: Person completing this form: Relation to client: Biological Father s Name: Age: Education: Name of Employer: Work Phone: May I contact you/him at this work #? Yes No May I leave a message? Yes No Type of Work: Home Phone: May I contact you/him at this home #? Yes No May I leave a message? Yes No E-mail address: Cell Phone: May I contact you/him on this cell phone? Yes No May I leave a message? Yes No Biological Mother s Name: Age: Education: Name of Employer: Work Phone: May I contact you/her at this work #? Yes No May I leave a message? Yes No Type of Work: Home Phone: May I contact you/her at this home #? Yes No May I leave a message? Yes No E-mail address: Cell Phone: May I contact you/her on this cell #? Yes No May I leave a message? Yes No If this client is a minor, and has experienced sexual, physical or emotional abuse, or neglect, to your knowledge has Child Protective Services ever been contacted or investigated a claim? Yes No Not applicable If yes, is there currently an open case with Child Protective Services involving this child? If client is a minor please complete the following: (If not, continue to page 9) His/her primary residence a: Single Parent Home Two Parent Home Other: Within the primary residence, child is living with: Both biological parents Biological Father Biological Mother Other: Other Children (living with this child): Name and age: Name and age: Name and age: Name and age: Other relatives or persons living in the home: This child has how many total: older siblings younger siblings older half-siblings younger half-siblings Is this child adopted? No Yes! 7
If yes, please describe the circumstance of the adoption: Marital Status of Primary Caregiver(s): Married (How long? ) Divorced (How long? ) Separated (How long? ) Single If divorced, who has custody? Mother Father Joint Custody Neither Specify: School Information: Name of School: Address of School: Phone Number: Current Grade (1 st, 2 nd, 11 th ) List Previous Schools and dates attended: Grades repeated: Grades skipped: Expelled? No Yes If yes, # of times? Any known learning disabilities? No Yes If yes, please explain: How does the school describe this child s current behavior? What does this child do best in at school?! 8