NANCY IREY HOLMES, PSY D Licensed Psychologist

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Transcription:

1. IDENTIFYING INFORMATION NANCY IREY HOLMES, PSY D Licensed Psychologist Portland: (503) 235-2466 Redmond: (541) 330-4428 www.nancyholmespsyd.com CLIENT INFORMATION Name: Date: Address: City, State, Zip: Phone(s): Home Work Other May I leave messages at Home? Circle Y or N At Work? Y or N Other? Y or N Gender: M F Age: Birthdate: SS#: Marital Status: Partner (if any): Spouse/Partner SS# (Optional) Education: Spouse/Partner Occupation: Employer: Spouse/Partner Occupation: Spouse/Partner Work Phone: Emergency Contact: Phone(s) Home: Work: Address: Relationship to Emergency Contact: Referral Source: Guardian (if Under 18): Address/Phone: Family Members Names Relationship Age Occupation/School Lives with you?

Client s Name: 2. Please Describe the Primary Problem(s) for Which You are Seeking Therapy: Please note any of the symptoms that you are having or have had recently. Indicate L (low), M (medium) or H (high). Problems getting along with others Memory problems Extreme sadness Thoughts about hurting yourself Change in sleep Habits Feeling helpless Change in eating habits Trouble concentrating Feeling hopeless Change in sexual interest/function Lack of energy Hopeless Concern about sexual orientation Self-esteem Problems Acting violently Lack of enjoyment of activities Trouble doing your job Feeling guilty Feelings of extreme happiness Muscle tension Perfectionism Physical complaints of pain Sudden feelings of panic Weight changes Thoughts about killing yourself Obsessions/ compulsions Feeling stressed Thoughts about killing others Problems with anger Easily irritated Thoughts about hurting others Depression Feeling nervous 3. Previous Mental Health Treatment: A. Please tell me about your previous therapists if any: Check here if none. Name Dates of Treatment Reason for Treatment OutCome B. Please tell me about any psychiatric hospitalizations: Check here if none. 4. Medical Information Your Primary Care Physician: Phone: Other Treating Health Care Practitioners: Phone:

Client s Name: Please List Current Medical Conditions: 1. 2. 3. Please List Any Allergies: Current Medications: Name Dosage/Day Condition Treating Who is Perscribing? How long Taken? 1. 2. 3. Please List Others On the Back. Indicate problems or conditions you have currently (use C ) or have had in the past (use P ) Muscle/Joint/Bone Headache Faintness Diabetes Appetite Problems Urinary Numbness Stroke Multiple Sclerosis HIV Positive Ulcers Tonsillitis High Cholesterol Kidney Disease Mumps Liver Disease Prostate Problem Measles Epilepsy Hepatitis Rheumatic Fever Scarlet Fever Tuberculosis Thyroid Fever Eye/Ear/Nose/Throat Sleep Problems Dizziness Weakness Chemical Dependence Stomach/Bowel Chest Pain Cancer Chicken Pox Asthma Arthritis Appendicitis Venereal Disease Alcoholism AIDS Genital Skin When was your last complete physical exam? Please list any major hospitalizations, with dates and conditions treated: 1. 2.

Client s Name: 5. Substance Use History Please indicate if you currently use or have used in the past the following substances: Past Current Amount Past Current Amount Tobacco/Cigarettes Amphetamines Caffeine (includes Cola, Coffee, ect.) Alcohol Cocaine Mushrooms Marijuana LSD Tranquilizers Psychedelics Pain Killers Sleeping Pills Over the Counter Meds Crank/Crack Prescription Meds Inhaleants (e.g. gas, glue, ect.) Other (Specify) Do you use or have you in the past used any of the above substances excessively? If so, please list the time period and amounts of excessive use: Please list any past or current facilities for substance abuse treatment (specify dates): 1. 2. 6. Other History A) Education Less than 12 years (specify highest grade completed) High School College (#of years completed if no degree) Master s Degree (specify) Doctoral Degree (specify) Did you receive special education? Yes No Learning Disability? Yes No

Client s Name: B) Occupation: Please list past job titles and dates 1. 2. 3. 4. C) Family Psychiatric History Please tell me about any family psychiatric history, including diagnoses and hospitalizations if you know them: THANK YOU FOR TAKING YOUR TIME TO FILL THIS OUT

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