+ Monica Michael MA LPC LLC

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Transcription:

+ Monica Michael MA LPC LLC 5242 Plainfield Ave NE, Suite C Grand Rapids, MI 49525-1084 Phone: 616.970.1599 Fax: 616.734-6205 Email: monica.m.michael@gmail.com Website: neurofeedbackcounselor.com Intake Form - - - Adolescent Full Name: Today s Date: Age: Birth Date: Male or Female (Circle One) Address: City/State: Zip: Grade: School: Emergency Contact Name Relationship to You: Emergency Contact Number: From Completed By: Handedness (Circle One) Left Right Mixed Relationship to Client: Eye Pain / Vial Sensitivity Please check all applicable options and add comments as needed I. Questions Regarding Overall Health: Date of last physical: Do you suffer from any of the following? A. Sleep Difficulty Falling Asleep or Staying Asleep Difficulty Waking Restless Sleep Sleepwalking/Night terrors/nightmares Bruxism (Grinding teeth) B. Auditory/Olfactory Ringing in the Ears Hearing Loss Ear aches Decrease in Sense of Smell Onset: Duration: Length: Quality: Dreams: D. Other Allergies C. Visual Asthma Double Vision Frequent illness Vision Problems/Blurred Vision Fatigue Blind Spots Chronic pain

E. Cardiovascular / Pulmonary Heart Problems Breathing Problems Palpitations or Tachycardia Hypertension F. Dermatological Skin Problems G. Endocrine Hot/ Cold Sensitivity Diabetes Sugar Sensitivity Excessive Thirst Appetite Awareness Thyroid Disorder PMS Incontinence H. Gastrointestinal Stomach Pain Chronic Constipation Irritable Bowel Nausea or Vomiting I. Neurological Headaches Fainting Tremor or Spasticity Coordination Speech Problems Accident Prone Weakness Balance Over- - - active Motor or Vocal Tics Seizures Under- - - active

J. Attention and Organization Attention Span Distractibility Impulsivity Organizational Ability K. Habits (Please indicate both past and present participation) Coffee Use Alcohol Use Cigarette Use Other Drug Use Dietary Habits (Please characterize your general eating habits L. Behavior/Emotions Mood Swings Eating Disorders Tantrums/Violent Behavior Panic Attacks Depression Risk- - - Taking Behavior Manic- - - Depression Anger/Aggression Obsessive Compulsive Anxiety Addictions Symptoms Irritability Fears/Phobias M. School Behavior and Performance Math Writing Problems with Spatial Skills Memory Homework Art Reading Teacher Complaints Verbal Expression Favorite Subjects (Strengths) Least Favorite Subjects (Weaknesses) N. Home Behavior Problems with Parents Problems with Siblings

II. Personal History A. Perinatal Prenatal Stress or Injury Prenatal Drug Exposure Medical Problems after Difficult Birth Premature or Late Birth Birth Adopted at age Difficult Labor B. Growth and Development Colic Sleep Problems Eating Problems Activity Level Attachment Emotional Development Motor Development Chronic Ear Infections Allergies Asthma Language Development C. Physical Traumas Head Injury Accidents Extreme Fever Serious Illness CNS Infection Drug Overdose Poisoning Anoxia Stroke D. Psychological Traumas and Stresses Abuse or Neglect Family Stress School/Job Stress Death in Family Illness E. Spiritual (Please be as specific as possible, estimating frequency of involvement) Prayer Fasting Meditation Bible/Wisdom Literature Reading Other Denominational Affiliation:

Treatment History Medications: (Use backside if more room is needed) Medication For Condition Dose Dates Medical Treatment: Procedure For Condition Physician Address/Phone Dates Psychological Therapy: Therapy For Condition Therapist Address/Phone Dates Other Therapy: Therapy For Condition Therapist Address/Phone Dates

Family History Symptom Yes No Relationship to You Asthma Autoimmune Disorders: Type 1 Diabetes, Rheumatoid Arthritis, Lupus, MS, Scleroderma, etc. Migraine Sleep Problems Depression Manic- - - Depression Anxiety Phobias Panic Attacks Motor or Vocal Tics Eating Disorders or Obesity Addictions Obsessive Compulsive Symptoms Speech Problems Attention Problems Learning Problems Conduct Problems or Criminal Behavior Autism Spectrum Schizophrenia

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