Fairview Counseling Centers Adult Intake Form

Fairview Counseling Centers Adult Intake Form Please complete as much of this form as you can. Bring the completed form to your first session. This information is vital to the treatment process. Your information Name Age Date of birth Month/Day/Year Referred by Emergency contact name Relationship to emergency contact Phone ( ) To be completed by therapist: MR#: Account #: Date of service: People present at the initial interview: (Name and relationship) Reviewed intake form and referral information. Client verbalizes understanding of informed consent and privacy policies. Completed release of information as indicated. Is there a phone number where your therapist can leave you a detailed message? yes no If yes, what is the number? Present concerns What has led you to seek help at this time? Have you already tried to resolve these concerns? If so, what did you do and how did it work? Who do you go to for support (family, friends, faith or spirituality, support or self-help groups)? 616512 Rev 03/09 ORIGINAL: To medical record Page 1 of 14 B1b

What strengths or resources do you have that will help your counseling succeed? (Examples include commitment, strong family support, intelligence, good social support, church, friends, etc.) What might interfere with your success in counseling? (Examples include few friends, financial stress, lack of social support, lack of family support, etc.) Social History Please check the item that best describes you below: Single Married Remarried Partner or significant other Separated Divorced Widowed Other Please describe your living situation. Check all that apply: With spouse With partner or significant other With children With parents Alone With roommate Other Please tell us if you are working. Check all that apply: Employed Unemployed Full-time parent Volunteer or other If you work outside the home (in a paying job or as a volunteer), describe the job and how long you have been in it: Which of the following best describes you? (Optional) African African American Asian Hawaiian or Pacific Islander Latino/Latina Native American Bi-racial White None of the above Tell us about your childhood: Where did you grow up? Were your parents always together, or was there a divorce? If they divorced, how old were you at the time? How many siblings do you have? What was your birth order? 616512 Rev 03/09 ORIGINAL: To medical record Page 2 of 14 B1b

How would you describe your childhood? Tell us about your current family. Please list the members of your family and household below. Name Age Relationship Living in same house? (circle) Yes No Yes Yes No No How would you describe relationships in your current family? Tell us about any other marriages or committed relationships you have had. Length of relationships: Do you have children from other relationships? yes no If yes, give names and ages (unless already included above): Legal status Have you ever been involved with the legal system (child custody, order for protection, DWI, etc.)? yes no If yes, please describe: Education Please list the highest grade level you have completed: Do you have learning problems in any of these areas? Speech Hearing Reading Writing Concentration Attention Other: None If you have problem areas or a preferred learning style, please describe: 616512 Rev 03/09 ORIGINAL: To medical record Page 3 of 14 B1b

Ethnicity, culture and religion Please share any ethnic, cultural or religious concerns that may be helpful to your therapist: Is English your preferred language? yes no If no, list language: Would you like an interpreter or other support involved in your therapy? yes no Mental health and chemical dependency in your family of origin Please list any biological relatives (blood relatives) who have had mental health issues. Depression: Bipolar/manic depression: Anxiety (panic attacks, obsessive-compulsive disorder, phobias): Schizophrenia: Suicide: Eating disorder: Attention deficit disorder: Drug or alcohol abuse or dependency: Your mental health and chemical dependency history Have you ever had therapy, counseling, hospital treatment or medicines for: Mental health problems? yes no Chemical dependency? yes no If yes, when, where and what was being treated? Date Treated For Treatment Type (hospital, medicine, counseling) Provider or Location of Care 616512 Rev 03/09 ORIGINAL: To medical record Page 4 of 14 B1b

Please complete the following. 1. In the past year, have you felt you ought to cut down on your drinking or yes no drug use? 2. In the past year, have you had people annoy you by criticizing your drinking yes no or drug use? 3. In the past year, have you felt bad or guilty about your drinking or drug use? yes no 4. In the past year, have you had a drink or used drugs as an eye-opener yes no first thing in the morning to steady your nerves, to get rid of a hangover or to get the day started? Please describe your current use of the following. Yes No Alcohol times per day/week/month/year (circle one). How much at a time? When did you first start using it? Tobacco times per day/week/month/year (circle one). How much at a time? When did you first start using it? Caffeine times per day/week/month/year (circle one). How much at a time? When did you first start using it? Marijuana times per day/week/month/year (circle one). How much at a time? When did you first start using it? Other:, times per day/week/month/year (circle one). How much at a time? When did you first start using it? Non-prescribed use of prescription or over-the-counter medicines times per day/week/month/year (circle one). How much at a time? When did you first start using it? List any problems you have had because of drinking or drug use (with friends, the law, your money, your job, sex, school, family): For therapist only Do not write in this area: Therapist discussed general effects of chemical use on health and well-being. Client given fact sheet discussing general effects of chemicals on health and well-being. 616512 Rev 03/09 ORIGINAL: To medical record Page 5 of 14 B1b

Trauma and abuse history Describe any major losses you have had (such as death, disability, divorce, relationship changes): Describe any trauma or abuse in your life (such as physical, sexual or emotional abuse; assault; neglect; domestic violence; witnessing the abuse of another, etc.): Physical abuse Sexual abuse Emotional abuse Neglect Assault Military-related trauma or distress Discrimination: Other Safety concerns Have you ever thought about hurting or killing yourself, or had an impulse to do so? yes no If yes, do you have a suicide plan? yes no If so, please explain: Have you ever tried to hurt or kill yourself? yes no If yes, list the date and method: Have you ever harmed property or other people, or thought about causing harm? yes no If yes, please explain: 616512 Rev 03/09 ORIGINAL: To medical record Page 6 of 14 B1b

Medical status (attach another page, if needed) Do you have a primary care clinic or doctor? yes no Name of clinic or doctor Phone ( ) Fax ( ) Have you had a physical exam to check for medical reasons for your symptoms? yes no Date of your last physical exam Do you have a psychiatrist? yes no Name of psychiatrist Phone ( ) Fax ( ) Date of last visit: Have you ever had any major medical problems? yes no If yes, please explain: Do you currently have any physical pain? yes no If yes, please explain: Is your pain constant or chronic (recurring or ongoing)? yes no Please circle your pain level below: 0 2 4 6 8 10 No pain Mild pain Moderate pain Severe pain Extreme pain As bad as it could be Are you concerned about your weight or eating habits? yes no Are other people concerned? yes no If yes to either question, please explain: 616512 Rev 03/09 ORIGINAL: To medical record Page 7 of 14 B1b

Medication Form Are you taking any medicines (prescribed or over-the-counter) or herbal products? yes no If yes, please list these below. EXAMPLE Medicine #1 Medicine #2 Medicine #3 Medicine #4 Medicine #5 Medicine #6 Name of medicine Celexa How many milligrams (mg)? 40 mg How many pills do you take at a time? one How many times a day do you take this medicine? once What time of day do you take this medicine? morning What does this medicine treat? depression Name of prescribing doctor Dr. John Doctor If you need more space, please attach another sheet of paper. Do you have any allergies? yes no Have you ever had a bad reaction to medicine? yes no If yes to either question, please describe: Client signature: Date: 616512 Rev 03/09 ORIGINAL: To medical record Page 8 of 14 B1b

Please check off and explain any symptoms you are having Symptoms or stressors When did it start? How often does it happen? Therapist notes (note mild, moderate or severe) Compulsive behavior (too much hand washing, checking, TV, spending) Grief (job loss, death, health ) Relationship problems Sexual issues (orientation, identity, function) Financial issues Racing thoughts Trouble making decisions Impulsive behavior Nightmares Muscle tension or headaches Feeling shaky Reviewed by Date (Therapist signature and credentials) 616512 Rev 03/09 ORIGINAL: To medical record Page 9 of 14 B1b

Please answer the following questions. PATIENT HEALTH QUESTIONNAIRE 9 Only the patient (subject) should enter information onto this questionnaire. Therapist notes Over the last 2 weeks, how often have you been bothered by any of the following problems? Not at all Several days More than half the days Nearly every day 1. Little interest or pleasure in doing things 0 1 2 3 2. Feeling down, depressed, or hopeless 0 1 2 3 3. Trouble falling or staying asleep, or sleeping too much 0 1 2 3 4. Feeling tired or having little energy 0 1 2 3 5. Poor appetite or overeating 0 1 2 3 6. Feeling bad about yourself or that you are a failure or have let yourself or your family down 7. Trouble concentrating on things, such as reading the newspaper or watching television 8. Moving or speaking so slowly that other people could have noticed? Or the opposite being so fidgety or restless that you have been moving around a lot more than usual 9. Thoughts that you would be better off dead or of hurting yourself in some way 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 SCORING FOR USE BY STUDY PERSONNEL ONLY: 0 + + + = Total Score: If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? Not difficult at all Somewhat difficult Very difficult Extremely difficult I confirm this information is accurate. Patient s/subject s initials: Date: Developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues, with an educational grant from Pfizer Inc. Copyright 2005 Pfizer, Inc. All rights reserved. Reproduced with permission. EPI0905.PHQ9P 616512 Rev 03/09 ORIGINAL: To medical record Page 10 of 14 B1b

Please answer the following questions. ZUNG SELF-RATING ANXIETY SCALE (SAS) Listed below are 20 statements. Please read each one carefully and decide how much the statement describes how you have been feeling during the past week. Circle the appropriate number for each statement. None or a little of the time Some of the time Good part of the time Most or all of the time Therapist notes 1. I feel more nervous and anxious than usual. 1 2 3 4 2. I feel afraid for no reason at all. 1 2 3 4 3. I get upset easily or feel panicky. 1 2 3 4 4. I feel like I'm falling apart and going to pieces. 5. I feel that everything is all right and nothing bad will happen 1 2 3 4 4 3 2 1 6. My arms and legs shake and tremble. 1 2 3 4 7. I am bothered by headaches, neck and back pain. 1 2 3 4 8. I feel weak and get tired easily. 1 2 3 4 9. I feel calm and can sit still easily. 4 3 2 1 10. I can feel my heart beating fast. 1 2 3 4 11. I am bothered by dizzy spells. 1 2 3 4 12. I have fainting spells or feel like it. 1 2 3 4 13. I can breathe in and out easily. 4 3 2 1 14. I get feelings of numbness and tingling in my fingers, toes. 15. I am bothered by stomach aches or indigestion. 1 2 3 4 1 2 3 4 16. I have to empty my bladder often. 1 2 3 4 17. My hands are usually warm and dry. 4 3 2 1 18. My face gets hot and blushes. 1 2 3 4 19. I fall asleep easily and get a good night's rest. 4 3 2 1 20. I have nightmares. 1 2 3 4 Score Total:* *Score is for healthcare provider interpretation. Source: William W.W.K. Zung. A rating instrument for anxiety disorders. Psychosomatics. 1971.` 616512 Rev 03/09 ORIGINAL: To medical record Page 11 of 14 B1b

Date faxed: FAIRVIEW COUNSELING CENTER Release to Psychiatrist Burnsville fax: 952-892-5674 Elk River fax: 763-241-5872 Minneapolis fax: 612-672-2691 Chisago City fax: 651-257-8414 Forest Lake fax: 651-464-4847 Princeton fax: 763-389-6455 Eden Prairie fax: 952-826-6606 Maple Grove/Bass Lake fax: 763-268-0455 Rogers fax: 763-488-4195 Edina fax: 952-924-5808 Milaca fax: 320-983-7474 Zimmerman fax: 763-856-6906 Client name (print): Date of birth: First Middle Last Phone: ( ) Phone: ( ) I allow Fairview Counseling Center: to provide written and verbal information to my psychiatrist related to the following. to receive written and verbal information from my psychiatrist related to the following. Diagnosis Treatment status Progress notes Medicines Referrals Phone consultation Other (specify): Doctor s name: Clinic name: Fax number: ( ) Phone: ( ) I understand that: I may refuse to sign this form. I can still receive treatment if I do not sign the form. This form expires one year after I sign it or sooner (specify time here: months). If I change my mind at any time, I may call 612-672-6999 to stop the release of my records. This will not apply to records that have already been released. It will not apply to my insurance company. Once the records are released, Fairview cannot prevent them from being released to a third party. Signature of client or guardian: Date: Client does not allow the release of information. Signature of therapist: Date: INITIAL ASSESSMENT SUMMARY (For therapist only Do not write in this area) was seen on for an Initial Assessment. Client name Month/Day/Year Initial DSM IV Diagnosis: Follow-up appointment:. Month/Day/Year Therapist Phone ( ) Fax ( ) Name / Credentials 616512 Rev 03/09 ORIGINAL: To medical record Page 12 of 14 B1b

Fairview Counseling Center Consent for Service I have reviewed and understand the information provided in the Fairview Counseling Center New Client Information packet. This includes details about the treatment process, my rights as a client, the client grievance (complaint) process, the privacy policy, the crisis intervention service and billing policies. I have also received a copy of the Patient's Bill of Rights. Consent for treatment: I agree to any care (tests, medicines, therapy, etc.) my therapist believes is needed. To give me this care, Fairview may get my medical information, including genetic information, as needed and appropriate. I know that specific results cannot be guaranteed. If I change my mind, I may end treatment at any time. Consent for release of information: Fairview may share my medical information with others Fairview providers involved in my treatment. Fairview may share and use my medical information to review and improve the quality of care provided. Fairview may store my medical information as long as required by Fairview s policies. I may take back this consent for release of information at any time by telling this facility in writing. If I do, it will not apply to information already released. Research consent: Unless I check the boxes below, I agree to let my medical records be used for research and to be contacted about future research studies. This may help science learn better ways to find and treat diseases. My name and other personal details will stay private. Researchers may not use my records. Researchers may not contact me about future research studies. Insurance consent: I ask for and agree to have insurance benefits paid to this facility and to providers of any services I receive here. Fairview may share my medical and account details with Medicare and other payers as needed for payment, claims, fraud investigations or quality of care reviews. For those with no (or not enough) insurance: Fairview has a screening program that may be used to determine if I might qualify for Medical Assistance or Fairview's Community Care Program. Pre-certification / prior authorization agreement: I must follow the rules of my insurer. I know that I may need the plan s prior permission ( pre-certification or prior authorization ) before it will pay for certain treatments. Guarantee of account: I agree to pay Fairview for all services not covered by a third-party payer (such as insurance). The total charges for the services I receive will not be known until my care has been completed. My account will be charged current rates for the care I receive. I can review these rates by calling 612-672-1048. My responsibility for the total charges will differ from other patients, depending on my insurance (or lack of it). I will ask the registration staff about options if I need help paying. Client signature: Date: (or legal representative s signture; list relationship to client) Client s printed name: 616512 Rev 03/09 ORIGINAL: To medical record Page 13 of 14 B1b

To be completed by therapist Do not write on this page Date faxed: FROM: FAIRVIEW COUNSELING CENTERS DATE: RE: Notification to Primary Care Provider of Service Contact with your Patient As part of our collaborative care standards, Fairview Counseling Center requests authorization from clients to notify their primary care provider and other health care providers that we are providing behavioral health care services. It is not uncommon for clients to experience co-occurring medical and mental health conditions and for the interaction between psychological/psychosocial stressors and physical health to impact overall health status. Clients experience enhanced care and improved health outcomes with effective communication and collaboration among involved health care providers. Dear: Please be informed that your patient DOB: Patient name (print) (M/D/Y) was seen for a diagnostic evaluation on Date (M/D/Y) The initial DSM-IV diagnosis is A follow-up appointment is scheduled for Date (M/D/Y) The evaluation was completed by Therapist name / credentials (print) AUTHORIZATION BY PATIENT TO SEND NOTIFICATION I understand that: I may refuse to sign this notification form. I can still receive treatment if I do not sign this form. Once this notification form is sent to my primary care provider, Fairview cannot prevent it from being released to a third party. Patient's or guardian s signature Date Patient declines to authorize notification Therapist Date Therapist signature / credentials Date 616512 Rev 03/09 ORIGINAL: To medical record Page 14 of 14 B1b