Counseling Associates, Inc.

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1522 Morgan Street Keokuk, IA 52632 (319) 524-0510 Counseling Associates, Inc. 1124 Avenue H Suite 2 Fort Madison, IA 52627 (319) 372-7689 Client Name: Date of Birth: Age: Counselor Name: Today s Date: Please fill out the information provided in these pages to ensure your therapist has the appropriate information regarding your care. What are the current issues that bring you to counseling?: What would you like to get out of counseling?: Please check any of the following that describe how you have been feeling lately: Depression Anxiety Sleep changes Appetite Changes Anger Fear Shame Worthless Tearful Moodiness Hopeless Helpless Aggressive Jealous Sad Irritable Confused Suicidal thoughts Homicidal thoughts (harm to others) Guilt Current Stressors: None Mild Stress Moderate Stress Severe Stress Family Friends Relationships Educational Economic Occupational Housing Legal Health What are your strengths and weaknesses? Strengths: Weaknesses: What allergies do you have? (Please include all allergies to medications, animals, etc.): 1

Abuse/Trauma History Circle if None NONE Please indicate if you have a history of verbal/sexual/physical abuse: Type of Abuse Age at Abuse Legal Outcome Type of Abuse Age at Abuse Legal Outcome Please indicate if you have any history of having experienced a traumatic event: Type of Trauma Age at Trauma Outcome Type of Trauma Age at Trauma Outcome Substance History Circle if None NONE If yes, please specify. Please fill out the information below regarding any history of substance use: Substance Used Age of Age of How was Amount Days per First Use Last Use it used? per Day Month Amphetamines/Speed Barbiturates/Downers Opiates Cocaine Psychedelics (ex. LSD, Ecstasy, Bath Salts, etc.) Inhalants (ex. glue, etc.) Cannabis/Marijuana/Hashish Benzodiazepines PCP Synthetics (K2 etc.) Other: Alcohol Use: Circle if None NONE If yes, please specify. Type of Alcohol: How much? How often do you drink this? Type of Alcohol: How much? How often do you drink this? Type of Alcohol: How much? How often do you drink this? Substance/Alcohol Use: Treatment History Have you received treatment for drug or alcohol use? YES NO If yes, please specify treatment history. Treatment Location How Many Age at Age at Outcome of Type Treatment Sessions First Visit Last Visit Treatment Inpatient Intensive Outpatient Outpatient 12-Step (AA, NA etc.) Other 2

Psychiatric History Inpatient Psychiatric History Circle if None NONE If yes, please specify treatment history. Hospital Treatment Reason for Age Outcome Voluntary? Hospitalization YES NO YES NO YES NO Outpatient Counseling History Circle if None NONE If yes, please specify treatment history. Provider Reason for Age of Age at Outcome Seeking Treatment First Treatment Last Treatment Suicide/Self-Harm/Homicide Have you ever tried to harm or kill yourself? YES NO Was your intent to die? YES NO How many times have you tried to harm or kill yourself? Have you ever engaged in self-mutilation (cutting/burning self, etc.) YES NO Have you ever tried to harm or kill someone else? YES NO Are you currently having thoughts of hurting yourself? YES NO Are you currently having thoughts of hurting someone else? YES NO Have you engaged in any self-harm behavior in the last month? YES NO Most Recent Suicide Attempt Date of Attempt (Month/Year): Method: Outcome (hospitalization, ER, etc.) Violence History Do you have a history of violent behavior? YES NO If yes, please explain: Family Psychiatric History Do you have any family members with a history of mental health issues? Family Member Mental Health Issues 3

Family Member Mental Health Issues Medical History Who is your primary physician? What medications are you currently taking? (Please list all medications) Medication Dose Reason for taking Prescribing Doctor How long? Do you have any of the following ongoing health concerns? (check all that apply): No problems Fibromyalgia Iron deficiency Allergies Anemia Anemia Arthritis Asthma Back problems Cancer Cataracts Chickenpox (as a child) Chronic Bronchitis COPD(Emphysema) Diabetes Diverticulitis Fainting spells/passing out Gall Bladder disease Gastritis or Ulcer Glaucoma Gout Hearing Loss Heart Disease Heart Valve problems Hepatitis HIV Hypertension Hypotension High Cholesterol Inflammatory Bowel Disease Kidney disease Kidney Stones Liver Disease Lupus Migraine Headaches Multiple Sclerosis Obesity/Overweight Parkinson s Disease Polyps Seizures Sleep Apnea Stroke/TIA Low Testosterone Thyroid problems Tuberculosis Other: Social History Developmental and Educational While pregnant with you, did your mother have problems with any of the following? Use of drugs or alcohol Difficult pregnancy Problems with delivery Other: None of these Did you have any complications after your birth? YES NO Did you have any of the following delays or difficulties? Walking Sleeping Alone Talking Making friends Toilet Training Being Away from Parents None of these 4

Which options best describe your childhood home atmosphere? Normal Frequent Moving Supportive Financial Difficulties Parental Fighting Parenting Violence Other: Which of the following challenges were experienced during your childhood? Tantrums Enuresis (bet wetting) Encopresis (bowel incontinence) Running away from home Fighting Stealing Property damage Fire setting Animal cruelty Separation Anxiety NONE Which of the following best describe problems you had in school? Fighting Truancy School Phobia Detentions Suspensions Expulsions School refusal Repetition of grades Special education Remedial classes NONE Did you have additional schooling outside of the standard classroom? (Check all that apply) Speech classes Accommodations Tutoring Other NONE Please select your highest level of education: Less than high school High School/GED Some college 2-year degree 4-year degree Technical school degree Graduated Professional Degree (MA, Ph.D., etc.) If you have any further information regarding your development or educational history, please do so in the space provided: General Social History Which option(s) best describe your social support situation? (Check all that apply) Supportive social network Few Friends Substance-use based friends No friends Distant from family of origin Family Conflict Other: What is your current marital status? Single, never married Married/Permanent partnership Divorced Widowed Separated What is the satisfaction level of your current relationship? Very satisfied Satisfied Somewhat satisfied Dissatisfied Not Applicable What is your current living situation? Rent (house/apartment) Own (house/condo) Group home Homeless Foster Care What are your current Hobbies or Interests? 5

Who currently lives with you? Name Age Relationship Name Age Relationship Do you currently participate in spiritual activities? YES NO What is your current occupational status? Employed Full-time Employed part-time Temporary/seasonal employment Part-time student Homemaker Unemployed (seeking work) Unemployed(not seeking work) Retired Disability Full-time student If working, what/where is your current occupation? How long have you worked here? Do you have any work-related concerns? Additional Information What other information would you like to share with your therapist prior to your appointment? 6

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