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Adult Patient Information Name:, Sex:, Age: Ethnicity, Race Date of Birth:, Email address: Address:, City: State:, County,, Zip: Telephone numbers: Home: ( ),Work: ( ) Cell: ( ) Referral by: Person to notify in case of emergency: Emergency Contact Telephone Number: ( ) School/ Employer: Marital Status: Insurance Company Information Name of Insurer: Member Number: Authorization Number: Insurer s Telephone Number: ( ) ; ( ) Insurer s email: [1]

Coordination of Care: Primary Care Doctor ; Phone number Email ; Telephone number Street ; City ; State Zip Therapist/Psychologist ; Phone number Email ; Telephone number Street ; City ; State Zip I agree to release my diagnosis and treatment recommendation information to my insurance company for billing and coordination of care: yes no I agree to release my diagnosis and treatment recommendation information to my primary care provider for coordination of care: yes no I agree to release diagnosis and treatment recommendation information to my therapist/psychologist for coordination of care: yes, no I would like help with the following problem/ symptoms. My Psychiatric Diagnoses are: [2]

Medical History Please indicate if you suffer from any of the following conditions, circle current, past or both and circle a number, 1 through 5 to indicate severity. 1 is mild, 3 is moderate, 5 is severe. Infectious diseases Current / Past 1 2 3 4 5 Allergies Current / Past 1 2 3 4 5 Asthma/lung disease Current / Past 1 2 3 4 5 Diabetes Current / Past 1 2 3 4 5 Thyroid disease Current / Past 1 2 3 4 5 Myocardial infarction Current / Past 1 2 3 4 5 Hypertension Current / Past 1 2 3 4 5 Liver disease Current / Past 1 2 3 4 5 Cancer Current / Past 1 2 3 4 5 Stroke Current / Past 1 2 3 4 5 Head injury Current / Past 1 2 3 4 5 Seizures Current / Past 1 2 3 4 5 Suffocation/ drowning Current / Past 1 2 3 4 5 Loss of consciousness Current / Past 1 2 3 4 5 Headaches Current / Past 1 2 3 4 5 Memory loss Current / Past 1 2 3 4 5 Neurological disorder Current / Past 1 2 3 4 5 Easy Bleeding/bruising Current / Past 1 2 3 4 5 Sexual dysfunction Current / Past 1 2 3 4 5 Pregnancy Current / Past 1 2 3 4 5 Menopause Current / Past 1 2 3 4 5 Kidney disease Current / Past 1 2 3 4 5 Chronic pain Current / Past 1 2 3 4 5 Excessive menstrual bleeding or Current / Past 1 2 3 4 5 pain Gynecological condition/procedure Current / Past 1 2 3 4 5 Skin Condition Current / Past 1 2 3 4 5 Surgical Procedures Current / Past 1 2 3 4 5 Medication Allergies: Please list all medications you are currently taking for medical illness: [3]

Family Psychiatric History Please indicate the blood relationship of your family members with a psychiatric condition as follows: 1 st degree relative biological child or parent; 2 nd degree- biological grandparent, cousin, uncle, aunt, niece, nephew Psychiatric care Maternal / Paternal 1 st degree/ 2 nd degree Anxiety disorder Maternal / Paternal 1 st degree/ 2 nd degree Depressive disorder Maternal / Paternal 1 st degree/ 2 nd degree Manic depression or Maternal / Paternal 1 st degree/ 2 nd degree Bipolar disorder Schizophrenia Maternal / Paternal 1 st degree/ 2 nd degree Psychotic disorder Maternal / Paternal 1 st degree/ 2 nd degree Attention deficit/ Maternal / Paternal 1 st degree/ 2 nd degree hyperactivity disorder Learning disorders Maternal / Paternal 1 st degree/ 2 nd degree Mental retardation Maternal / Paternal 1 st degree/ 2 nd degree Autistic disorder Maternal / Paternal 1 st degree/ 2 nd degree Substance abuse Maternal / Paternal 1 st degree/ 2 nd degree Psychiatric Maternal / Paternal 1 st degree/ 2 nd degree hospitalization Eating Disorder Maternal / Paternal 1 st degree/ 2 nd degree Narcolepsy Maternal / Paternal 1 st degree/ 2 nd degree Sleep disturbance Maternal / Paternal 1 st degree/ 2 nd degree Homicide attempt Maternal / Paternal 1 st degree/ 2 nd degree Suicide attempt Maternal / Paternal 1 st degree/ 2 nd degree Social History of Client: Highest degree of education obtained: With whom do you live? [4]

Type of employment: Sexual Orientation: Number of Children: Legal problems/ circumstances: Main source of stress: Negative experiences physical or sexual abuse, domestic violence, trauma, loss: Personal strengths/ weaknesses: Personal goals/aspirations/ hopes/ dreams: Spiritual/religious orientation/cultural issues [5]

Psychiatric History of Client Please indicate any psychiatric/ psychological care you have received, your approximate age at that time and your satisfaction with the treatment: List all psychiatric medications prescribed; the reason prescribed; the duration; and effect by completing the following table. Name of medication Reason prescribed Date started Date ended/ reason for stopping Helpful? Yes/No Side effects? [6]

Psychiatric History Continued: Please indicate if the following is current, past or both. Please indicate the frequency using the following scale: Almost Never (1); Sometimes (3); Almost Always (5) Depression Symptoms When Frequency Depressed mood Current / Past 1 2 3 4 5 Loss of pleasure Current / Past 1 2 3 4 5 Loneliness Current / Past 1 2 3 4 5 Decreased appetite Current / Past 1 2 3 4 5 Increased appetite Current / Past 1 2 3 4 5 Poor concentration Current / Past 1 2 3 4 5 Crying spells Current / Past 1 2 3 4 5 Suicide thoughts Current / Past 1 2 3 4 5 Homicide thoughts Current / Past 1 2 3 4 5 Isolation Current / Past 1 2 3 4 5 Irritability Current / Past 1 2 3 4 5 Weight loss Current / Past 1 2 3 4 5 Weight gain Current / Past 1 2 3 4 5 Anger Current / Past 1 2 3 4 5 Mania Symptoms When Frequency Increased energy Current / Past 1 2 3 4 5 Racing thoughts Current / Past 1 2 3 4 5 Rapid speech Current / Past 1 2 3 4 5 Less than four hours Current / Past 1 2 3 4 5 sleep per night Euphoria Current / Past 1 2 3 4 5 Invincibility Current / Past 1 2 3 4 5 Irritability Current / Past 1 2 3 4 5 Anger Current / Past 1 2 3 4 5 Violent outburst Current / Past 1 2 3 4 5 Sexual impulsivity Current / Past 1 2 3 4 5 Financial impulsivity Current / Past 1 2 3 4 5 Mood swings Current / Past 1 2 3 4 5 [7]

Anxiety Symptoms When Frequency Excessive worrying Current / Past 1 2 3 4 5 Muscle stiffness Current / Past 1 2 3 4 5 Panic attacks Current / Past 1 2 3 4 5 Avoiding things Current / Past 1 2 3 4 5 Unwanted fears Current / Past 1 2 3 4 5 Unwanted rituals Current / Past 1 2 3 4 5 Unwanted habits Current / Past 1 2 3 4 5 Procrastination Current / Past 1 2 3 4 5 Psychosis Symptoms When Frequency Hearing voices Current / Past 1 2 3 4 5 Seeing things Current / Past 1 2 3 4 5 Paranoia Current / Past 1 2 3 4 5 Special powers Current / Past 1 2 3 4 5 TV, Radio, News talks to you or about you personally Current / Past 1 2 3 4 5 ADHD Symptoms When Frequency Overly active Current / Past 1 2 3 4 5 Constantly in motion Current / Past 1 2 3 4 5 Constantly talking Current / Past 1 2 3 4 5 Constantly interrupting Current / Past 1 2 3 4 5 Annoying to peers Current / Past 1 2 3 4 5 Annoying to adults Current / Past 1 2 3 4 5 Constantly distracted Current / Past 1 2 3 4 5 Forgetful Current / Past 1 2 3 4 5 Inattentive Current / Past 1 2 3 4 5 [8]

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