Client Information Form

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Transcription:

Today s Date: Client Information Form Note: If you have been a client here before, please fill in only the information that has changed. If you are seeking services as a couple, each member must complete an information form (but redundant information can be entered on only one form). A. Identification Your name: Date of birth: Age: Gender: Nicknames or aliases: Social Security #: Billing Address: City: State: Zip: Phone(s): E-mail(s): Calls or e-mail will be discreet, but please indicate any restrictions: B. Emergency Information If some kind of emergency arises and we cannot reach you directly, or we need to reach someone close to you: whom should we call? (Note: Your emergency person will not be contacted except in a genuine emergency) Name: Relationship: Phone 1: Phone 2: C. Referral Who gave you my/our name to call? Psychology Today website ArchPsychotherapy.com website Other (please indicate below) Name: Contact: May we have your permission to thank this person for the referral? Yes No 1

D. Chief Concern & Current Symptoms Please describe the main difficulty that has brought you to see us: E. Religious, Racial/Ethnic, and Sexual Identification Current religious denomination/affiliation: Protestant Catholic Jewish Islamic Buddhist Hindu Atheist/Agnostic Other (specify): Involvement: None Some/irregular Active Race/ethnicity/national origin: Sexuality: Heterosexual/straight Gay Lesbian Bisexual Questioning Other: Specify any other important aspect of how you identify yourself: F. Career and Education Highest level of education completed: Current occupation: Significant prior work experiences: School (if student): Military history: Indicate any important information about your occupation or career identity: 2

G. Family History Please list any significant family members. Then indicate any mental health issues (including depression, anxiety, addictions, etc.) experienced by family members in last column. Name Relationship to you (e.g. mother) Deceased? Age (or age at time of death) Mental Health (if applicable) H. Marital / Partner / Significant Other History Current significant other: Gender: Quality of relationship: Important past significant others: I. Children Indicate those from a previous marriage or relationship with P in last column. Name Age Gender Grade Quality of Relationship P? 3

J. Health Please indicate any significant health issues you experience or have experienced as well as any treatment (e.g. medications) for them: K. Mental Health History Please list any mental health concerns you have experienced in the past as well as whether you were treated for them (include medications, outpatient psychotherapy, partial hospitalization/residential programs, and inpatient psychiatric hospitalizations). Nature of Concern When? Treatment Received/Provider L. Trauma/Abuse History Have you experienced any abuse or life threatening events? None Physical Abuse Emotional Abuse Sexual Abuse Sexual Assault Unsure Other trauma (specify): Do you currently reside with the person who hurt you? 4

M. Substance Use 1. How many cups of regular coffee do you drink each day? How many cups of tea? How many sodas/pop with caffeine (Coke, Pepsi, Mountain Dew, Dr. Pepper, etc.)? How many energy drinks? How often do you use No-Doz or similar caffeine pills? 2. How much tobacco do you smoke or chew each week? 3. How much beer, wine, or hard liquor do you consume each week, on average? 4. Which drugs (not medications prescribed for you) have you used in the last 10 years? 5. Have you ever felt the need to cut down on your drinking/drug use? No Yes 6. Have you ever felt annoyed by criticism of your drinking/drug use? No Yes 7. Have you ever felt guilty about your drinking/drug use? No Yes 8. Have you ever taken a morning eye-opener? No Yes 9. Are there times when you drink to unconsciousness, or run out of money as a result of drinking or drug use? No Yes N. Current Symptoms Please check any of the following that you have been experiencing lately: Little interest or pleasure in doing things Feeling down, depressed, or hopeless Feeling more irritated, grouchy, or angry than usual Sleeping less than usual, but still have a lot of energy Sleeping much more than usual and still not feeling rested Starting lots more projects than usual or doing more risky things than usual Feeling nervous, anxious, frightened, worried, or on edge Feeling panic or being frightened Avoiding situations that make you anxious 5

Unexplained aches and pains (e.g., head, back, joints, abdomen, legs) Thoughts of actually hurting yourself Hearing things other people couldn t hear, such as voices even when no one was around Feeling that someone could hear your thoughts, or that you could hear what another person was thinking Problems with sleep that affected your sleep quality overall Problems with memory (e.g., learning new information) or with location (e.g., finding your way home) Unpleasant thoughts, urges, or images that repeatedly enter your mind Feeling driven to perform certain behaviors or mental acts over and over again Feeling detached or distant from yourself, your body, your physical surroundings, or your memories Thinking a lot about food, thinness, or your appearance O. Legal History Are you currently involved in any legal issues? Please describe. Do you expect any legal issues to affect your care here? Have you ever been incarcerated? If so, why and for how long? P. Any other information you think your clinician should know: 6

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