Integrity Counseling & Coaching CLIENT INFORMATION FORM

Integrity Counseling & Coaching CLIENT INFORMATION FORM NAME: DATE: ADDRESS: CITY: ZIP: HOME #: WORK #: CELL #: MAY WE LEAVE DISCREET MESSAGES AS NEEDED AT ABOVE LISTED NUMBERS? YES NO EMAIL: MAY WE CONTACT YOU AT THIS EMAIL? YES NO SOCIAL SECURITY NUMBER: DOB: AGE: NAME AND NUMBER OF EMERGENCY CONTACT PERSON: HOW DID YOU HEAR ABOUT INTEGRITY COUNSELING? BRIEFLY DESCRIBE THE ISSUES/PROBLEMS THAT LED YOU TO SEEK THERAPY TODAY: WHAT GOALS WOULD YOU LIKE TO ACHIEVE IN THERAPY? DESCRIBE ANY HEALTH PROBLEMS, MEDICAL CONDITIONS, OR RECENT OPERATIONS: ALLERGIES: LIST ALL MEDICATIONS YOU ARE TAKING: LIST YOUR PHYSICIAN(S) NAME(S): LIST ANY PAST PSYCHOLOGICAL/PSYCHIATRIC/COUNSELING/TREATMENT YOU HAVE HAD: HOW OFTEN DO YOU DRINK ALCOHOL? IS THERE ALCOHOLISM IN YOUR FAMILY? WHAT ILLICIT DRUGS HAVE YOU USED? DO YOU BELIEVE YOU HAVE, OR HAD AT ANY TIME IN THE PAST, A PROBLEM WITH ALCOHOL OR DRUGS? EXPLAIN: IS THERE ANYTHING ELSE WE SHOULD KNOW? PLEASE READ AND SIGN THE REVERSE SIDE OF THIS FORM

Integrity Counseling & Coaching FINANCIAL POLICY Full payment is due at time of service (unless prior arrangements have been made). Please feel free to ask if you have any questions about our financial policy. Understanding our financial policy is important to our relationship. Insurance is a contract between you and your insurance company. We will file your claim to your insurance company or provide you with the proper information needed for you to file a claim. You are responsible for the timely payment of your Account. We will send information, including clinical information i.e. diagnosis, to your insurance company unless you specifically instruct us not to do so. We will send information electronically, so please read the HIPPA notice. Uncollected balances may be turned over for collection or reported to the state s attorney s office. CANCELLATION POLICY Please help us to serve you and others better by keeping your scheduled appointments. If you need to cancel or reschedule, please give us as much notice as possible so we can offer that time to someone else. Unless cancelled at least 24 hours in advance, our policy is to charge for missed appointments at the rate of a normal counseling session. This will be billed to you. We may require prepayment in order to schedule a subsequent appointment. CONFIDENTIALITY Federal and State laws protect your confidentiality (See 42 U.S.C. 290dd-3 and 290ee-3 for Federal laws and 42 CFR Part 2, 491.0147 FL). Your counselor will not share information with any person outside of Integrity Counseling, Inc. without your written permission, except as required by law or as needed to file your insurance claim. Information obtained from minors is not generally shared with parents without permission. Exceptions to Confidentiality: Federal regulations do not protect from disclosure of information related to a client s involvement in a crime against property or personnel. We are required under State law to report suspected abuse of a child, elderly person, or individual with a disability. We may share limited information in the event of a medical emergency or in the event of a specialized court order signed by a judge. Your counselor has the option of breeching confidentiality if you report a specific plan or intent to cause serious bodily harm to an identifiable person. HIPPA (Health Insurance Portability and Accountability Act) laws allow you access to your file and protect the electronic transfer of information. CONSENT TO TREATMENT I am voluntarily seeking outpatient counseling at Integrity Counseling & Coaching. I understand that I have rights and responsibilities regarding my participation in treatment, including the right to discontinue therapy. I am strongly encouraged to discuss my treatment plan and status in treatment with my counselor. Counselors will also discuss alternatives, procedures, qualifications, and drawbacks to therapy. With my signature below, I acknowledge that I have read, understand, and agree to all of the above. I also acknowledge that I have been given a copy of HIPPA/Privacy Practices implemented here at Integrity. Individual counseling sessions are intended to be 45-50 minutes in length. Please note: We do not provide emergency services. In true crisis call 911. Signature of Client and/or Legal Guardian Date

Psychosocial History Name: DOB: Today s date: FAMILY HISTORY Is your father living? Father s age: Where does your father live? Father s occupation: Father s values growing up: Describe your relationship with your father now: What was it like growing up? Is your mother living? Mother s age: Where does your mother live? Mother s occupation: Mother s values growing up: Describe your relationship with your mother now: What was it like growing up? Describe your parents relationship with each other (when you were a child): What is it like now? Do/did you have step-parents? Describe your relationship: List the names and ages of your brothers and sisters: Are you the oldest youngest middle child? Are/were there major cultural or religious influences in your family? Describe: Describe your family growing up: Describe your childhood: Describe your current religious or spiritual beliefs/practices: How has substance use affected your religious or spiritual beliefs/practices? Number of marriages/partners: Marital/partner status: How long? Children (names and ages): Which children are living with you? How has your use of alcohol/drugs affected your family relationships?

Are any of your family members alcoholics or chemically dependent? (answer below) Mother Father Siblings Step Parents Yes No Yes No Aunts/Uncles Grandparents Children Spouse/partner How did the family you grew up in affect who you are today? SEXUAL HISTORY How did you learn about sex? How old were you when you began dating? What did you do on dates? Describe your first sexual experience: Were you using? How has alcohol/substance use affected your sex life? Were you ever sexually abused? Describe any current sexual concerns: EDUCATION/MILITARY HISTORY Growing up what was school like for you? Highest grade completed: Current employment status: What has been your major field of employment (trade, profession)? Military history (branch, rank, length of service, discharge type, disciplinary proceedings): LEGAL HISTORY Arrest history: dates and reasons: Describe any current legal issues, including probation: SOCIAL HISTORY Where/with whom do you currently live? What do you do in your spare time? Who do you turn to for support? What percentage of your friends drink/use drugs? Have they ever commented on your drinking/drug use?

EMOTIONAL HISTORY Have you ever been in counseling? If so, what was helpful? List the names of past therapists: What was not helpful? Answer accordingly for the past year: never rarely sometimes often regularly I have difficulty sleeping I have difficulty eating well or with appetite I have difficulty concentrating I feel down or depressed I have thought about suicide or harming myself I have felt restless or edgy I have felt irritable I worry or feel anxious I hear voices or see things that others do not I think of harming other people How has your alcohol/drug use affected your emotional life? Have you experienced abuse or trauma? SUBSTANCE USE HISTORY Have you ever tried to cut down on your drinking/drug use? yes no been annoyed by others commenting about your drinking/drug use? yes no felt guilty about your drinking/drug use? yes no drank/used to eliminate a hangover? yes no Alcohol Age 1 st used Date last used Amount Frequency Circumstances of use Currently using? Marijuana Cocaine Stimulants Tranquilizers Heroin Pain medication Hallucinogens Steroids Nicotine Caffeine Other

Treatment history for drinking/drug use: Names of treatment facilities/providers: Dates of treatment: Outcomes: Describe your patterns of alcohol/drug use over your lifetime, and note any changes in patterns: Is there anything more you want to share? Client Signature: Therapist Signature: Date: Date: For Office Use Only ASSESSMENT

Medical History Name: Date: General How would you describe your current health? Do you have any medical concerns? Are you receiving any medical treatment? What type? When was your last physical examination? Do you have any allergies? What? Has your health been effected in any way by your use of drugs including alcohol? Do you or have you had any of the following? Mark x for yes: Anemia Anxiety Bleeding Breathing/Lung Problems Bowel/Stomach Trouble Convulsions/Seizures Depression Diabetes Headaches Head injury Heart/Blood Pressure Problems Kidney Problems Liver Trouble OB/GYN Problems Pancreatitis List all medications you are taking and the prescribing doctor/ ARNP S If you are taking mood or mind altering prescription drugs your prescribing doctor/arnp will be notified of your participation in treatment and their input will be invited. This is for the protection & benefit of all of us. If you test positive for prescription drugs without a legal prescription, this will be seen as abuse of drugs. Emotional Have you had any changes in eating? sleeping? Explain: Have you experienced periods of tearfulness? sadness? loss of interest in activities? Periods of hopelessness? Do you ever think of suicide? harming yourself? others? Do you experience difficulty with fearfulness? worry too much? have trouble concentrating? Do you have trouble controlling your temper? Explain: Substance abusing individuals are at higher risk for contracting HIV/AIDS, Hepatitis, Tuberculosis, sexually transmitted diseases (STD s) as well as other communicable diseases. We encourage you to get accurate information and anonymous/confidential testing. We will gladly help you get anonymous/confidential testing and treatment there are good assistance programs available. Please ask! Over

Our licensing by The Department of Children and Families requires us to do both screening and education about communicable diseases. New cases must be reported to The Department of Health. We ask people to practice courtesy and general good hygiene including universal precautions and seeing a doctor when sick. A copy of our infection control policy is available to you. We will gladly answer questions you may have. Hepatitis is a disease of the liver. There are several types of Hepatitis and people who are infected may not know it because they don t have symptoms yet. Chronic Hepatitis B & C are two of the most serious types which can be life threatening. Early detection can help save lives because treatment is available. Hepatitis can be transmitted through body fluids such as blood, semen, and vaginal fluids. Most commonly these fluids are exchanged during sexual contact, by piercing & tattooing, or by sharing paraphernalia used to smoke, snort, or shoot drugs. Hepatitis is also transmitted by contact with fecal stool, which is the reason for the signs in restaurant bathrooms. It is generally accepted that Hepatitis is not spread by casual contact. Testing is available through your doctor or at the Health Department. Symptoms of Hepatitis include tiredness or fatigue, flu-like symptoms, loss of appetite, nausea, vomiting, fever, and weakness. You can protect yourself from exposure by abstaining from sex and drug use. Safer sex and not sharing paraphernalia reduce exposure risks. We have handouts that provide additional information. HIV (Human Immunodeficiency Virus) is the virus that causes AIDS (Acquired Immunodeficiency Syndrome). People with HIV/AIDS may look healthy. Again, early detection can lead to life preserving and life enhancing treatment. HIV/AIDS can be transmitted through body fluids such as blood, semen, vaginal fluid, and sometimes breast milk. It is transmittable through oral, anal, and vaginal sex. It is transmittable through the sharing of needles including those used for drugs, piercing, and tattooing. HIV/AIDS is not spread through casual contact. Anonymous testing is available at the Health Department. Symptoms of AIDS often do not occur for many years after infection with HIV, and the infected person is contagious during this time. Again testing can save the lives of others as well as help the infected person receive proper treatment. You can protect yourself from exposure by abstaining from sex and use of needles. Safer sex including avoiding high-risk behavior reduces exposure risks. We have handouts available for more information. Tuberculosis is a disease spread from person to person through germs in the air. Tuberculosis usually affects the lungs, but can affect other organs. More powerful strains of Tuberculosis are occurring and infection is on the rise. There are higher risk situations including exposure to confined spaces such as institutions or planes. Testing is available through your doctor or at the Health Department. Symptoms of Tuberculosis include feeling sick or weak, weight loss, fever, night sweats, cough, coughing up blood, and chest pain. We ask that people practice coughing into their elbow. For a demonstration or for additional information, please ask. Have you ever? Screening (check all that apply) Do you have? Shared a needle? Had a tattoo or piercing? Had sex with a prostitute? Had sex for money or drugs? Had unprotected sex outside a monogamous relationship? Had multiple sex partners in the past year? Had a STD? Had a blackout while drinking or using other drugs? Had sex with someone who would answer yes to any of these questions? Night sweats? Fatigue? Flu-like symptoms? Cough? Cough up blood? Fever? Have you had? A recent HIV test? A recent Hepatitis test? A recent Tuberculosis test? Risk Level Low Medium High For anonymous/confidential testing call the Pinellas County Health Department @ (727) 824-6911 SIGNATURE DATE

PATIENT: Because alcohol use can affect your health and can interfere with certain medications and treatments, it is important that we ask some questions about your use of alcohol. Your answers will remain confidential, so please be honest. Place an X in one box that best describes your answer to each question. Name: Date: Questions 0 1 2 3 4 1. How often do you have a drink containing alcohol? 2. How many drinks containing alcohol do you have on a typical day when you are drinking? 3. How often do you have 5 or more drinks on one occasion? 4. How often during the last year have you found that you were not able to stop drinking once you had started? 5. How often during the last year have you failed to do what was normally expected of you because of drinking? 6. How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session? 7. How often during the last year have you had a feeling of guilt or remorse after drinking? 8. How often during the last year have you been unable to remember what happened the night before because of your drinking? 9. Have you or someone else been injured because of your drinking? 10. Has a relative, friend, doctor, or other health care worker been concerned about your drinking or suggested you cut down? Monthly or less 2 to 4 times a month 2 to 3 times a week 4 or more times a week 1 or 2 3 or 4 5 or 6 7 to 9 10 or more No No Less than monthly Less than monthly Less than monthly Less than monthly Less than monthly Less than monthly Monthly Monthly Monthly Monthly Monthly Monthly Yes, but not in the last year Yes, but not in the last year Weekly Weekly Weekly Weekly Weekly Weekly Daily or almost daily Daily or almost daily Daily or almost daily Daily or almost daily Daily or almost daily Daily or almost daily Yes, during the last year Yes, during the last year Total -World Health Organization