5400 Laurel Springs Parkway Suite 1101 Suwanee, GA 30024 678-90-5543

5400 Laurel Springs Parkway Suite 1101 Suwanee, GA 30024 678-90-5543

Kelley Therapeutic Services, LLC—Lisa Kelley MSW LCSW

5400 Laurel Springs Parkway Suite 1101 Suwanee, GA 30024 678-90-5543

Client Self Report-Adult

Today’s Date:

Client Name: Age: Date of Birth:

  1. Briefly describe the issue that brings you here today:
  2. What do you want to see changed:
  3. What kind of help do you want from Kelley Therapeutic Services:

Check below any behaviors/symptoms issues the client has difficulty with:


hyperactivesadexcessive worry

impulsivesleep problemspanic attacks

underachievementnegative thinkingirrational fear

non-compliantpoor concentrationobsessions

inattentivehopeless/worthlesssocial isolation

poor concentrationmood swingsphobias



marital/significant othershort fusedalcohol

parentingtemper tantrumsdrugs

difficulty with friendsimpulse controlgambling

work/school problemsviolent/assaultiverelationships/sex

personal growthrunaway riskeating disorders







domestic violenceparanoia



dissociativecutting behavior

appetite changes


eating disorders

  1. Are you now or have you ever had thoughts of hurting yourself or someone else? Yes No

If yes please describe.

Psychiatric Treatment

  1. Have you ever been treated for psychiatric, substance abuse, emotional or behavioral problems in the past? Yes No

If yes when, where and with whom?

Provider Name:

counselorpsychiatristpsychologistsubstance abuse counselor

Psychiatric medications currently taking and effectiveness:

  1. Did you find past treatment helpful? YesN o

If yes, how?

If no, why not?

  1. Please list any medications given:
  2. Are you currently under the care of a psychiatrist or therapist for your current problem? YesNo
  3. Are you currently taking any medications for psychiatric problems? YesNo

If yes, please list:

Medical Issues

  1. Does you have any current medical problems or health issues? YesNo

If yes please list:

  1. When was the last time you were seen by a doctor?
  2. Would you like information from today’s visit communicated with your doctor? YesNo
  3. Are you currently taking medications for medical issues?YesNo

If yes please list:

  1. Are there any allergies and/or medication allergies?YesNo

If yes please list:

  1. Is there any history of head injury, seizures, loss of consciousness, or extended high fevers? Yes No If yes please list:
  2. (Women only) Are you pregnant? YesNo
  3. Do you have pain management issues? YesNo

Substance Use/Abuse

  1. Have you been treated for drugs, alcohol, or other addictions?YesNo
  2. Do you currently attend support groups?YesNo
  3. Does anyone in your household have problems with drugs, alcohol, or other addictions? Yes No
  4. Check any of the following you have used in the past 30 days:

alcoholmarijuanatranquilizerssleeping pills

pain killersheroincocaine/crackamphetamines/speed


  1. Have you experienced withdrawal symptoms? YesNo

If yes check all that apply:


seeing thingshearing thingsintoxicated

  1. Have you ever had a DUI/DWI? YesNo

Legal Issues

  1. Do you have current legal issues?YesNo

If yes please list:

  1. Are you currently on probation or parole?YesNo
  2. Are there any legal issues such as:
  3. divorce in process
  4. possible custody battle
  5. going to court
  6. other:
  7. Is a DFACS worker involved?YesNo

Educational/Work Issues

  1. Check current employment status: Full Part Time Unemployeed Homemaker Student Disabled Retired
  2. Are you currently on leave from work or seeking medical leave/disability? Yes No

If yes, do you have paperwork that needs completing? Yes No

  1. Check educational background: Current student Did not complete high school High school graduate GED Some college Associates degree Undergraduate degree Advanced degree
  2. Did you experience difficulties in school? Yes No


  1. Please list anyone who lives in the home, his/her age, and relationship:
  1. Does anyone in the immediate family have psychiatric, emotional, substance abuse, or behavioral problems? Yes No

If so please describe:

  1. Is your immediate family supportive of you seeking treatment?YesNo
  2. Does anyone in your extended family have psychiatric, emotional, substance abuse, or behavioral problems? Yes No

If yes, please describe:

  1. Do you have any domestic violence history or current issues? Yes No
  2. Do you have any history of sexual and/or physical abuse? Yes No
  3. Please rate your support network (i.e. friends, family, neighbors, religious organizations, etc): good fair poor
  4. List any spiritual/cultural/ethnic considerations that could impact therapy:
  5. List your strengths/resources and hobbies/interests:
  6. Do you have difficulties or concerns about how you get along with other people? Yes No
  7. Are you having difficulty with spiritual or religious matters? Yes No
  8. Do you have any sexual orientation/gender issues or concerns? Yes No

Treatment Access/Mobility

  1. Are there any financial concerns that would affect your ability to access treatment? Yes No
  2. Do you have access to transportation?YesNo
  3. Do you have any disabilities, special needs, or other restrictions that may impact treatment or access to treatment? Yes No

Client (or person completing this form) signatureDate

Therapist signature/credentialsDate