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

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CLIENT QUESTIONNAIRE Full Legal Name: DOB: / / Preferred Name: Email: Address: (Street) (City/State) (Zip Code) Home Phone: Cell Phone: Can we leave voice messages for you at these numbers? Yes Text Messages? Yes EMERGENCY CONTACT INFORMATION: Name: Home Phone: Relationship: Cell Phone: Name: Home Phone: Relationship: Cell Phone: Hospital Preference: CULTURAL PREFERENCES: Ethnic Identification: African American Caucasian Latino Hispanic Asian Native American Other, Please Explain: Sexual Identification: Heterosexual (Straight) Gay/Lesbian Bisexual Other, Please Explain: Religious/Spirituality Identification: Catholic Protestant n-denominational Christian Jewish Hindu Muslim Buddhist Agnostic Athiest Jehovah s Witness Other: Please Explain: Are you satisfied with your spirituality? Yes Please Explain: Gender Identity and Expression:

Marital Status: Single Partnered/Cohabitating Married Divorced Separated Widowed Other, Please Explain: Employment Status: Employed FT Employed PT Student FT Student PT Self-Empl. Unemployed Other, Please Explain: Please tell us a little bit about what is bringing you in today: PSYCHOLOGICAL SYMPTOMS AND HISTORY: Please check any of the following that are currently bothering you: Feeling Tense Past or Present Trauma Feeling Lonely Low Motivation/Energy Level Hopelessness Suicidal Thoughts Mood Swings Racing Thoughts Worrying about what others think of me Negative thoughts about myself Eating Disorder Sleeping Too Much Problems Falling or Staying Asleep Grief or Loss Difficulty Controlling Anger Substance Use Gambling Seeing or hearing things that other people don t Couple s/relationship Problems Worrying too much/feeling afraid Avoiding things I am afraid of Isolating/Withdrawing Feeling Numb Crying Easily Self-Injury Difficulty Making Decisions Feeling High (Without Substance Use) Seeking reassurance from others My Weight/Appearance Chronic Pain t Sleeping Enough Nightmares Irritability Being violent or wanting to be violent Sex Addiction Impulsivity Difficulty Controlling Thoughts Problems with my Kids

HAVE YOU EVER EXPERIENCED THE FOLLOWING: Physical Abuse Sexual Abuse Emotional/Verbal Abuse Neglect Have you ever abused another person? Yes Have you ever experienced a life-threatening event (i.e. combat, natural disaster, accident, serious injury, watched another person die, violent crime, etc.)? Yes PAST TREATMENT EXPERIENCES: Have you ever participated in mental health treatment in the past? Yes If so, please describe: Has anyone in your immediate family ever struggled with mental health conditions (i.e. anxiety, depression, suicide, substance use, etc.): Yes If so, please describe: HEALTH INFORMATION: Who is your primary care physician? Date of your last primary care visit: / / Would you like to sign a release of information to involve them in your care with us? Yes If you are experiencing any current medical conditions that you believe could impact your mental health treatment, please describe them here:

Please list all of the medications (prescribed or over-the-counter) that you are currently taking: Medication: Dosage: Prescribed By: Please list any psychiatric medications that you have been prescribed in the past: Who is your current psychiatrist? Date of your last psychiatry visit: / / Would you like to sign a release of information to involve them in your care with us? Yes If you do not currently have a psychiatrist, are you interested in a referral for one? Yes

SUBSTANCE USE SCREENING: Please fill out the following chart regarding your substance use history (only complete boxes 5-11 for substances that you are currently using): 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. Type of Substance: Current Use? Used in the Past? Age of First Use? How often and how much do you use (example: 4 beers 3 times/week or $20 worth 2 times/week)? Withdrawal symptoms when you stop using? Have you ever tried to stop or cut down? Have you ever taken more than planned? Has it caused problems (at work, financial, in relationships, health, etc)? Tolerance (have to use more to get the same effect)? Have you continued to use despite it making your problems worse? Alcohol Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Cannabis/Marijuana Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Opiates Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Cocaine Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Benzodiazepines Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Hallucinogens Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Inhalants Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Caffeine Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Nico tine Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N FAMILY INFORMATION: Please tell us about the other people living in your home: Name: Relationship to You: Age: Comments:

Do you have additional children who are not currently living in your home? Yes If so, please list them here: Name: Age: Living With: Comments: Please list additional family members below (i.e. parents, siblings, step-family, adoptive family, ex-partners of importance, etc.): Name: Relationship to You: Age (or age at death): Comments (please comment if deceased): EDUCATIONAL/OCCUPATIONAL HISTORY: What is the highest level of education that you completed? Middle School GED High School Diploma Some College, Degree Associate s Degree Bachelor s Degree Master s Degree Doctorate Do you have any difficulties with learning? Yes Difficulties with reading/writing? Yes What do you identify as your strengths that will help you achieve your goals?

Please list the past five jobs that you have had: Place of Employment: Position: Length of Time Employed: Comments: Did you ever serve in the U.S. military? Yes If so, what branch? What years did you serve? Did you experience combat? Yes LEGAL HISTORY: What is your current legal status: Clear Awaiting Trial Probation Parole Other, Please Explain: If you are currently experiencing legal problems, would you like to sign a release of information for your legal providers? Yes Please list any past legal charges and/or incarcerations: Dates: Charges: Results (probation, incarceration. etc.):

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