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:

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Transcription:

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 messages for you at home? Yes / No May we leave messages for you at work? Yes / No Gender: M / F Age: Birth Date: Marital Status: Others Living in Home (name, age, relationship to client): Highest Level of Education: Occupation: Client s Employer: (optional) Emergency Contact: Relationship to client Phone: Referred by / How did you hear about our services? May we acknowledge our meeting to any referral source? Have you received previous counseling and /or substance abuse treatment: yes no If Yes, Name & number of therapist/ Agency (optional) Past Diagnoses? Months / Years in treatment Name & number of primary care physician or health practitioner (optional) Name & number of psychiatrist or psychiatric nurse practitioner (optional) Any current medical or mental health conditions being treated? Any current medications? yes no [If yes, please list & include daily dose amounts] *Do we have your permission to discuss or receive treatment records and/or to receive diagnostic records from your past or current therapist, psychiatrist, and/or physician and/ or to disclose or share our clinical information with your past or current therapist, psychiatrist, and/or physician? yes no [A Release of Information-ROI form will be provided to you, if yes.] **Signature [required] Date [required] FOR OFFICE USE ONLY: CLINICIAN S CREDENTIALS: LH 60321405 DIAGNOSTIC CODE:

Personal & Family Information Ethnic identity & background Current relationship status My birth parents currently: married/ live together separated divorced never lived together one or both deceased Family of Origin [parents/ step parents, adoptive parents, siblings] Name Relationship to you Age or deceased Current Family & Household [partner/spouse, roommates, children] Name Relationship to you Age or deceased Check all that apply: (History of) Family of Origin Current Family & Household Counseling Alcohol dependence Drug dependence Chronic physical Illness Chronic mental illness Depression Anxiety Eating Disorders Domestic Violence Sex Abuse and/ or Incest Psychiatric hospitalization Suicide Attempts (check all that apply) I use alcohol: never daily Occasionally how many drinks on average per week I use drugs: never daily Occasionally how many times on average per week I use tobacco: never daily Occasionally how much on average per week I have experienced an unwanted sexual experience: recently in the past If yes, please indicate: sexual assault date rape rape incest My sleep is: hours a night / Frequent waking? (y/n) / Difficulty falling asleep? (y/n) Staying asleep? (y/n) I am dissatisfied with my personal appearance (y/n) I have felt like or tried to hurt myself in the past (y/n) I m currently hurting myself or thinking of hurting myself (y/n) I have suffered a recent significant loss or death (y/n) I have suffered a recent relationship ending (y/n) other loss (y/n) (Please list) I have experienced: (y/n) medical complications at birth (y/n) serious head injury (or knocked out) (y/n) past learning disability or attention deficit/ hyperactivity disorder (y/n) permanent disability (if checked yes, please describe) (y/n) legal difficulties (if checked yes, please describe)

Please state briefly your reasons for seeking services at this time. What do you think may be getting in the way of you resolving your current problems or concerns? What are a few of your current goals that you wish to achieve while participating in counseling, and how do you currently believe you can best achieve those goals? How would you like things to be different after you have participated in counseling/ psychotherapy? If you could wake up tomorrow with a different life or in a different situation, what would that life look like?

Symptom Checklist Please mark any of the following symptoms past or present and circle a number between 1 & 5. (If the item does not apply to you, please leave it blank.) Past / Present / Level of severity Past: Interfered with daily living in the past Present: Interferes with daily living or causes you mild to extreme distress 1: Little to no distress (symptoms occur infrequently, causes no interference with daily living) 3: Moderate distress (symptoms occur more often than not, moderate interference with daily living) 5: Severe distress (occurs daily, extreme interference with daily living) Depressed mood most of the day, nearly every day Loss of interest or pleasure Significant weight change Sleeping too much Loss of energy Fatigue Sleeping too little Feeling worthless or helpless Difficult concentrating or indecisiveness Feeling slowed down Recurrent thoughts of death Thoughts of suicide Feeling guilt Lack of motivation Feeling like a failure Feeling unattractive Feeling pessimistic about the future Self-blame or criticism Loneliness Easily distracted Feeling extra high or good Increased goal directed activity Grandiosity Little or no need for sleep Behavior that has caused problems Increased involvement in pleasurable activates with negative consequences Feeling agitated Racing thoughts Poor judgment Significant mood swings

Acts of violent behavior/ uncontrollable anger or rage Destroying property Stealing items Pulling out hair Harming self Preoccupation with the Internet Preoccupation with shopping or spending Preoccupation with sex Preoccupation with gambling Preoccupation with fire or starting fires Thoughts of harming others Hearing things that aren t there Seeing things that aren t there Feeling or sensing things that aren t there Feeling like I am being punished Feeling like others are out to get me Difficulty getting along with others Drug abuse or dependence Alcohol abuse or dependence Falling asleep from drinking or using drugs Treatment for drugs or alcohol Drug or alcohol related legal issues Blackouts Withdrawal symptoms from drugs or alcohol High tolerance to drugs or alcohol Fear of losing control Fear the worst happening Feeling dizzy or faint Fear of dying Sensations of shortness of breath Trembling or shaking Chest pain or discomfort Feeling of choking Panic Attacks

Having recurrent/persistent thought or worries Doing repetitive behaviors when nervous Feeling excess anxiety about being in certain situations Difficulty asserting yourself Irritability Restlessness Muscle tension Difficulty concentrating or mind going blank History of sexual abuse History of physical abuse History of emotional abuse Experience of traumatic events Recurrent troubling memories Recurrent distressing dreams Exaggerated response to being startled Outbursts of anger Feeling hypervigilant Fear of assault by strangers Flashbacks Lesbian, gay, bisexual, transgender, queer, intersex, asexual concerns (please circle appropriate concern) Acculturation concerns (multicultural issues) Religious or spiritual concerns and issues Problems in romantic relationships Problems with intimacy Lack of interest in sex Harassment related to my gender identity or sexual orientation Sexual concerns Pain during sex Difficulty having or sustaining an erection Other sexual concerns related to men (please describe) Other sexual concerns related to women (please describe)

Relationship problems Divorce Family or sibling problems Problems related to occupation or relationships at work Difficulty parenting Transitional concerns (difficulty adjusting) Environmental concerns Difficulty expressing emotions Difficulty setting boundaries Memory problems Headaches Physical pain (please describe) Poor appetite Overeating Limiting food intake, vomiting, and laxatives to control weight Binge eating Preoccupation with exercise Weight change of five pounds or more in last month Other concerns or issues: (Please list below)

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