San Diego Center for the Treatment of Mood Disorders 1

Similar documents
MINDFUL WELLNESS CENTER, PLLC

Client Information Form

ADULT PATIENT HISTORY FORM. Name: Address: City: State: Zip: Occupation (if applicable): Religious Affiliation (if applicable):

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:

Full Circle Psychotherapy: Ayla Marie Carter, MA, LMHC

Family Life Counseling, P.C.

Life, Family and Relationship Questionnaire

A New Tomorrow Behavioral Health Services

BACKGROUND HISTORY QUESTIONNAIRE

Sonja Benson, Ph.D., PLLC Licensed Psychologist

Name: Gender: male female Age: Date of birth: / / Preferred phone: cell home work other. Alternate phone: cell home work other.

Restore Counseling Center 630 E Southlake Blvd, Ste 127, Southlake, Tx

ADULT HISTORY QUESTIONNAIRE

FMS Psychology, PLLC Adult Intake Form. Phone Number (Day): Phone Number (Evening):

Client s Name: Street City State Zip. Home Phone Work Phone Cell Phone. Student: Full-time Part-time Grade School. Current or past Education:

CERTIFICATION AND AUTHORIZATION (if applicable)

Lyris Bacchus Steuber, MS, LMFT MT Harley Lester Lane Apopka, FL Ph: , Fax:

ADULT QUESTIONNAIRE. Date of Birth: Briefly describe the history and development of this issue from onset to present.

CLIENT QUESTIONNAIRE. Preferred Name: Address: (Street) (City/State) (Zip Code) Home Phone: Cell Phone: Relationship: Cell Phone:

Do not write below this line DSM IV Code: Primary Secondary. Clinical Information

Atlanta Psychological Services

Intake Questionnaire

Christina Pucel Counseling 416 W. Main St Monongahela, PA /

Psychiatric Nurse Practitioner Intake Form. General Information. 1. Name. 2. Date of Birth. 3. Age. 4. Gender. 5. Referred by

ADULT INTAKE FORM. Name

Diana Valdez, PhD, LPC

Deborah L. Galindo, Psy.D th St. SE, Ste 420 Salem, OR Phone: Fax: (503) or (503)

COUNSELING INTAKE FORM

MERLE MULLINS COUNSELING REGISTRATION FORM (Please Print) CLIENT INFORMATION

New Client Information. address: Date of Birth:

CHEMICAL USE EVALUATION INTERVIEW. A. Demographics

Client Information Form

PHARMACY INFORMATION:

JILL L. KOFENDER, PHD, PLLC. Licensed Clinical Psychologist ADULT CLIENT QUESTIONNAIRE. Client s Name Today s Date Gender Age Birthdate

PSYCHIATRIC INTAKE AND TREATMENT PLAN-PART I TO BE FILLED BY PATIENT PLEASE PRINT

Preferred Name (s): Local Address: City: State: Zip: Permanent Address: City: State: Zip: Years of Education: Occupation: Gender: M F

Client Intake History

Last Name First Middle Date of Birth Age. Residence Address City State Zip Code

LEXIE SMITH LPC 116 W. 7th, Suite 211 Stillwater, OK Date. Personal History Information

ADULT INITIAL EVALUATION: Patient Form

Nebraska Bariatric Medicine 8207 Northwoods Dr., Suite 101 Lincoln, NE MEDICAL HISTORY

Sleep Health Center. You have been scheduled for an Insomnia Treatment Program consultation to further discuss your

Katarina R. Mansir, Psy.D. Licensed Psychologist PSY25417 (858) Name: Date: Presenting Concerns

Depression Care. Patient Education Script

ADULT INTAKE QUESTIONNAIRE. Ok to leave message? Yes No. Present psychological difficulties please check any that apply to you at this time.

Understanding Perinatal Mood Disorders (PMD)

PERSONAL HISTORY What are your strengths? (i.e. skills, positive qualities or characteristics) Hobbies/Extracurricular Activities (Please list): ETHNI

EMOTIONAL SUPPORT ANIMAL (ESA) PSYCHOLOGICAL EVALUATION PART I: PERSONAL INFORMATION STREET ADDRESS CITY/STATE

Getting Help for Patients with Dementia and their Caregivers. Erica Salamida Associate Director of Programs and Services Alzheimer s Association-NENY

Conscious Living Counseling & Education Center 3239 Oak Ridge Loop East, West Fargo ND (701)

medical questionnaire Date: Day Month Year

CBT Intake Form. Patient Name: Preferred Name: Last. First. Best contact phone number: address: Address:

TOOL 1: QUESTIONS BY ASAM DIMENSIONS

CHEMICAL DEPENDENCY EVALUATION INTERVIEW. A. Demographics

Crawford consulting and mental health services, inc ADULT PSYCHOSOCIAL ASSESSMENT

APPLICATION FOR ADMISSION

Street City State Zip Code Social Security No: Telephone: Home: Marital Status: Q Single Work: Q Married Cell: Q Divorced

Journey to Truth Counseling

Anxiety Depression Sleep problems Thoughts of suicide. Panic Unusual thoughts Anger outbursts Changes in weight

Child s name: Nickname: Date of Birth: / / Sex: Male Female SSN: Today s date: / / Parent s Name #1: Home phone: ( ) Cell: ( )

Patient Questionnaire. Name: Date: A. What are the main concerns or problems that brought you here today?

EMOTIONAL SUPPORT ANIMAL (ESA) PSYCHOLOGICAL EVALUATION. Important Information

SANDSTONE PSYCHOLOGICAL PRACTICE

Name:, Sex:, Age: Ethnicity, Race. Date of Birth:, address: Address:, City: State:, County,, Zip: Telephone numbers: Home: ( ),Work: ( )

Abusing drugs can reduce the effectiveness of your treatment, prolong your illness and increase the risk of side effects.

Community Data Explorer. Depression History Questionnaire (exported at 1/28/2013 6:44:11 AM) Questionnaire Completion History

COUNSELING ASSESSMENT REFERRAL AND BACKGROUND INFORMATION (Adult Form) cell telephones/fax #s/ addresses: (Spouse): (Emergency Contact):

Elana Klemm, LPC, NCC Compassionate Care Counseling 4343 Shallowford Rd. Suite H-1B Marietta, GA ( ) NEW CLIENT INFORMATION

Application and History for Adult

Emotional Problems After Traumatic Brain Injury (TBI)

ALVIN C. BURSTEIN, MD PATIENT CLIENT INFORMATION

BETHESDA WORKSHOPS: HEALING FOR MEN PARTICIPANT INFORMATION FORM

PSYCHOLOGICAL EVALUTAION QUESTIONNAIRE

COLUMBUS PSYCHOLOGICAL ASSOCIATES, L.L.P.

Bipolar Disorder. TeensHealth.org A safe, private place to get doctor-approved information on health, emotions, and life. What Is Bipolar Disorder?

PHONE: RELATIONSHIP: ADDRESS:

Postnatal anxiety and depression

ADULT INFORMATION SHEET

Natural Health Center

Address: City/State/Zip: Home Phone: Cell: Pager: Work Phone: Employer/School: Emergency Contact: Phone:

Address: Spouse/Partner Name: Phone: Address:

Intake Information Form

MERCY HOUSE RESIDENT APPLICATION FORM

UNDERSTANDING DEPRESSION Young Adult: Get the Facts

Depression Fact Sheet

Module. Managing Feelings About. Heart Failure

Associates of Behavioral Health Northwest CHILD/ADOLESCENT PSYCHOSOCIAL ASSESSMENT

Name: Date: Who referred you? Current Psychiatrist: Clinical Information:

Chapter 20 Psychosocial Nursing of the Physically Ill Client Psychosocial Assessment Interactive process that involves gathering data and evaluating

Client Intake Form. First Name: M.I.: Last Name: Birthdate: Gender: Age: Address: City: State: Zip:

Depression During and After Pregnancy

Biology Change Pressure Identity and Self-Image

Depression: More than just the blues

NANCY IREY HOLMES, PSY D Licensed Psychologist

What is stress? A type of response that typically involves an unpleasant state, such as anxiety or tension (page 469).

ADULT History Form (To be filled out by the person seeking treatment)

Emotional Changes After a Traumatic Brain Injury

Depression During and After Pregnancy

DBSA Survey Center Depression Experiences and Treatments Survey

Mental Health Referral Form

Transcription:

San Diego Center for the Treatment of Mood Disorders 1 DATE NAME Last Middle First REFERRAL HISTORY: How did you find us (via a referral, web search, recommendation)? Please provide the name and phone number of you family physician: Please provide the name and phone number of any specialists that you consult: IDENTIFYING AND BILLING INFORMATION: Social Security number: Driver s license number: Age: Date of Birth: Home phone number: Cell phone number: Work phone number: In what country, city, were you born: OCCUPATION Job description: If not employed currently when was the last time that you worked? EDUCATION HISTORY Highest grade you completed? Name of high school? Name of college (if applicable)? Additional Degrees (if applicable)?

San Diego Center for the Treatment of Mood Disorders 2 MARITAL HISTORY If you are currently married: What year were you married? What is the name of your spouse? Have you been married more than once? If so, how many times? If you are currently divorced what year did you and your partner separate? FAMILY HISTORY: If you have children, please list their names and ages: Psychiatric Illnesses: To the best of your knowledge, has anyone in your immediate family struggled with a problem similar to yours? What family member? If more than one family member has struggled with a psychiatric illness similar to yours, please list their names and whether they were treated for said problem: PSYCHIATRIC HISTORY Previous Episodes: Have you had a similar episode in the past? If so, please list the dates of previous episodes: Treatment: Were you treated for a similar episode? Who treated the episode?

San Diego Center for the Treatment of Mood Disorders 3 Medication: If you were treated with medication, please list the name and dosage of the medication(s): Diagnosis: Have you ever been officially diagnosed with a psychiatric diagnosis? If so, what was it? PROBLEM HISTORY: Severity Rating: Please use the numbers below to rate the severity of the problem(s) for which you are seeking help. A score of 0 indicates no problem, and a score of 10 indicates the worst level of problem. No Problem 0 1 2 3 4 5 6 7 8 9 10 Worst Problem Please use select from this list the problem(s) for which you are seeking help and use the severity numbers to grade each of the problems for which you are seeking help (Or if you would rather, use you own words to describe your problem Check all that Apply Problem Type Anxious Worried Fearful Trouble Concentrating Sleep Problems Depressed Sad Avoidance of Friends/Family Feelings of Worthlessness Loss of Ability to Experience Pleasurable Activities Loss of Motivation Loss of Energy Mood Swings Irritability Anger Stress at Work Stressful Medical Problems Financial Stress Recent Death or Loss of a Family Member Severity Level (0=None: 10=Worst)

San Diego Center for the Treatment of Mood Disorders 4 DRUG AND ALCOHOL HISTORY Drugs & Alcohol: Are there, or were there, any drug or alcohol problems in your family? If so, which family members have struggled with drugs or alcohol? Have you ever abused alcohol? If so, how old were you when you last abused alcohol? Have you ever used drugs? If so, how old were you when you last used? Have you ever been treated for a drug or alcohol problem, and if so, please describe the treatment: FUNCTIONAL HISTORY What aspect of your problem do you feel interferes the most with your day to day life? _ Has your problem made it difficult or impossible to do the things that you do every day? _ What things in particular have become difficult? Have you ever had to miss work for the problem that you came here for help? How many times? ABUSE AND OR MOLESTATION HISTORY Have you ever been abused? If you were abused as a child, describe it: Emotional abuse? Physical abuse? _ Sexual abuse? If you were abused as an adult, please describe it: Emotional abuse?

San Diego Center for the Treatment of Mood Disorders 5 Physical abuse? _ Sexual abuse? If yes to any of the above, please answer the following questions: Who abused you? How often? GENERAL MEDICAL HISTORY If you have any additional medical problems, please list them below: If you are currently taking any medications, please list the names of the medications and dosages in the spaces provided: If you have you ever been hospitalized, please include a list of list below, beginning with the most recent dates: Hospitalization Date Location Reason for Hospitalization

2024 © healthdocbox.com Privacy Policy | Terms of Service | Feedback