Date of Assessment ADULT PSYCHOSOCIAL HISTORY/INITIAL THERAPY INTAKE FORM Identifying Information: Name: Address: Age: D.O.B: Phone Number: Race: Gender: Religious Affiliation(optional): Current Household Composition: REASONS FOR REFERRAL: Why you are you seeking services? Check symptoms described or observed and how often the symptom(s) present. Circle appropriate number : (1-Mild, 2-Moderate, 3-Severe) How Often? How Often? Anxious 1 2 3 Poor Self- Esteem 1 2 3 Panic Attacks 1 2 3 Depressed Moods 1 2 3 Repetitive Thoughts 1 2 3 Physical Symptoms 1 2 3 Repetitive Behaviors 1 2 3 Poor Concentration 1 2 3 Guilt 1 2 3 Mood Change 1 2 3 Fear of Leaving Home 1 2 3 Irritability 1 2 3 Excess Talking 1 2 3 Sleep Disturbances 1 2 3 Sleep Disturbances 1 2 3 Worthlessness 1 2 3 Poor Memory 1 2 3 Uncomfortable Thoughts 1 2 3 Decreased Energy Seeing/Hearing things and Interest 1 2 3 that may not be present 1 2 3 Significant Appetite Change 1 2 3 Suspiciousness 1 2 3 Weight Loss lbs. 1 2 3 Impulsiveness 1 2 3 Weight Gain lbs. 1 2 3 Temper Problems 1 2 3 Tearfulness 1 2 3 Grief 1 2 3 Other 1 2 3 Eating Disorder 1 2 3 Sexual Assault 1 2 3 CURRENT CONCERNS/ NEEDS: What do you hope to receive through counseling? History of Presenting Concerns: Client Name: Clinician Name & Credentials:
PERSONAL HISTORY What are your strengths? (i.e. skills, positive qualities or characteristics) Hobbies/Extracurricular Activities (Please list): ETHNIC/CULTURA L/SPIRITUA L CONCERNS Raised Outside The U.S.: No Yes Where: How long have you lived in the U.S? Any cultural, ethnic, or spiritual concerns that may effect your treatment? No Yes (please list) EMPLOYM ENT HISTORY: Employer s Name (optional): Occupation: Longest continuous employment in the last ten years: MILITARY HISTORY: Yes No Branch of Service: Served From: to Type of Discharge FIREARMS REVIEW : Guns/Ammunition Maintained at Home: Security/Storage of Firearms: LEGAL: Current charges pending: Yes No Charged with: Current probation/parole: Yes No Charges: Prior Arrests/Incarcerations: Yes No Why: When: Any involvement with Children s Bureau? Yes No If Yes, Describe: Have you applied for: Supplemental Security Income Public Welfare Benefits Social Security Disability Worker s Compensation Client Name: Clinician Name & Credentials:
SUBSTANCES USED: Tobacco Never: Current: Past: How long ago? Substance used: Cigarettes Pipe/Cigars Chewing Tobacco Ecig/Vape Alcohol Never: Current: Past: How long ago? Substance used: Beer Wine Liquor Caffeine: Never: Current: Past: How long ago? Substance used: Coffee Tea Soda Other (list: ) Stimulants Never: Current: Past: How long ago? Type of use: Prescribed Recreational Substance used: Methamphetamine Adderall Cocaine Other (list: ) Marijuana: Never: Current: Past: How long ago? Type of use: Prescribed Recreational Opiates/Opiods: Never: Current: Past: How long ago? Type of use: Prescribed Recreational Substance used: Heroin Codeine Oxycodone Morphine Fentanyl Hydrocodone Methadone Other (list: ) Phencyclidine (PCP): Never: Current: Past: How long ago? Type of use: Recreational Sedatives: Never: Current: Past: How long ago? Type of use: Prescribed Recreational Substance used: Barbiturates Benzodiazepines Other (list: ) Client Name: Clinician Name & Credentials:
MEDICAL HISTORY Medication Allergies: Yes No If Yes: Medications: Reaction: Serious Medical Condition: What? When? CURRENT MEDICATIONS: (Including prescriptions and over the counter medications) Medication: Dosage: Physician: PHARMACY INFORMATION : (Please list Name, Address, and Phone Number of the pharmacy you most often use in the case medication is prescribed. Name: Address: Phone Number: PRIOR PSYCHIATRIC TREATMENT HISTORY: Describe past counseling treatment experience for yourself (when, how long, how effective): Past Psychiatric Diagnosis: Past Psychiatric Hospitalizations: PRIOR PSYCHIATRIC MEDICATIONS: Yes No Client Name: Clinician Name & Credentials:
If Yes: Medications: Helpful: Yes No Yes No Yes No Yes No Do you have nightmares or reoccurring dreams? If so, please describe. SUICIDAL ASSESSMENT: Thoughts: Occasional Frequent None Prior Suicide Attempts: Yes No If Yes, When? Method: Treatment: Yes No If Yes, Where: RELATIONS HIP/ MARITAL HISTORY If married: Length of Current Marriage: Date of Marriage: Quality of Marriage: Previous Marriages: Length of Marriage: Date of Marriage: Reason for Termination: Any additional comments regarding marital history: Current relationship status: Going back as far as you can remember, have there been any significant deaths/losses in you life? If so, please describe. Have you ever been in any other past significant relationships? If so, please describe. Client Name: Clinician Name & Credentials:
If you have children, please describe your partner s parenting style. What traits about your partner initially attracted you to him/her? What are some hopes for your current relationship with your partner? Have you ever had a miscarriage or been in a relationship when there was a miscarriage? If so, what effect did this have on you? Have you ever had an abortion or been in a relationship where the was one? If so, what effect did this have on you? ABUSE HISTORY: Have you ever been abused: Physically Yes No Emotionally Yes No Sexually Yes No If yes, please describe: Going back as far as you can remember, have there been any times that you have been kicked, hit, slapped, or otherwise physically hurt? If so, please describe. Going back as far as you can remember, has anyone significantly older to you made any kind of sexual adv ances to you? If so, please describe. Client Name: Clinician Name & Credentials:
Have you ever been raped? Please describe (when did this occur, effect on you, etc.) Have you ever been forced into any sexual relationship that you were not comfortable with? FAMILY HISTORY: (List people who live in your home and their relationship to you.) Any family member (s) who have emotional/psychiatric problems: Yes No If Yes, please list: Family Member: Type of Problem: Treatment: Yes No Yes No Yes No Yes No Yes No Yes No Describe history of alcohol, substance abuse issues and/or problems with prescription medications with yourself and/or family of origin members. Are your parents alive or deceased? If alive, do they live in close proximity to you and how often do you have contact with them? Describe your present and/or past relationship with Mother, Father, Step- Mother, Other Parent Figure. Describe your parent s style of parenting when you were growing up? Client Name: Clinician Name & Credentials:
Do you have siblings? If so, how many? Describe your relationships with your siblings/how often do you have contact with them? Is there anything I didn t ask that has had a signifigant impact on your life? Please add any signifigant information about yourself, or your situation, that would be helpful to us to know, as your plan of treatment is developed: What do you believe would be most helpful for your treatment: Do you have a Advanced Mental Health Directive? Yes or If yes, please supply a copy for your file. No Emergency Contact Information 1. Name: Address: Phone: 2. Name: Address: Phone: Client Name: Clinician Name & Credentials:
THERAPIST USE PCP Notified: Yes No Refused Primary Care Physician: Phone #: Address: How long have they been a patient? Client Rights Provided: Yes No CLINICIAN S IMPRESSIONS/S UMMARY: PROVISIONAL DIAGNOS IS: AXIS I: AXIS II: AXIS III: AXIS IV: AXIS V: Current GAF: Highest In The Past Year: Intake Clinician s Signature: Credentials: Date: Client Name: Clinician Name & Credentials: