Brightside Counseling LLC
Personal Data Inventory
Please fill out the sheet as thoroughly as possible. All information is confidential and for our records only.
Client Name: / Date of Birth:Address: / City: / State: / Zip:
Home Phone: / Business and/or Cell Phone:
Occupation:
Marital Status: / Single / Married / Separated / Divorced / Widowed
Education (Last year completed):
Other Training:
MARRIAGE AND FAMILY INFORMATION
Address: / City: / State: / Zip:
Home Phone: / Business and/or Cell Phone:
Occupation:
Is your spouse willing to come for counseling? / Yes / No / Not Sure
Have you ever been separated? / Yes / No / When? / From / To
Have either of you ever filed for divorce? / Yes / No / When?
Date of Marriage: / Any previous marriages? / Yes / No / When?
List children and ages:
Educational Background
School:
RELIGIOUS BACKGROUND
Denominational Preference:Church attended in childhood:
Religious background of spouse (if married):
Is faith an important part of your life? Explain:
HEALTH HISTORY
Date of last medical exam: / Family Doctor / Phone
Address
Current medications:
Condition / Medication / Dose (mg) / Frequency / Duration / Compliant? (y/n) / Start Date / Effective? (y/n)Allergies/reactions to drugs:
Have you ever used drugs for purposes other than medical? If yes, explain.
CHEMICAL USE HISTORY
Route: 0=Oral
1= Nasal
2=Smoking
3=Injection
4=IV Injection
Frequency: 0=None
1=Sporadic
2=1-3 Times Weekly
3= 4-6 Times Weekly
4= Daily
How long was your most recent period of abstinence? (In days, weeks, month and/or years)
How long ago did it end? (Day, week, month, year)
Have you ever experienced any of the following withdrawal symptoms? (yes/no)
Seizures? / DT’s? / Hallucinations?
Do you have an active addict living in the house? (yes/no)
Do you have a non-chemically dependent social contacts who could provide support during recovery? (yes/no)
Do you currently smoke cigarettes or have you in the past? (yes/no)
If yes: Present use in number of cigarettes daily: / Duration of use in years:
Past cigarette use: / Duration of use in years:
Level of Care
Previous mental health (MH) and substance abuse (SA) treatment: Please list most recent first.
Inpatient, outpatient or
day program / Duration / Condition
(MH or SA) / Outcome
Family/Environmental
List any history of mental health or substance abuse diagnoses in your family using specific labels such as “alcoholism” or “depression.”
Mental Health
Substance Abuse
AUTHORIZATION
I hereby authorize Brightside Counseling LLC“X“ one: / To release any applicable mental health information to my primary care physician named above.
To release any applicable substance abuse information to my PCP named above.
To release only medical information to my PCP named above.
Not to release any information to my PCP named above.
I may not revoke this authorization at any time except to the extent that action has been taken in reliance upon it. If I do not revoke this authorization, it will expire one (1) year after I have terminated treatment.
Print name of Client or Guardian / ID Number / Date of Birth
Signature of Patient or Guardian / Date
Adult Screening
Feelings / Never or Rarely (0) / Sometimes (1) / Often (2) / Almost Always (3)I feel sad.
I feel like a failure.
I have lost interest in my work.
I do not look forward to the future.
I feel guilty.
I have lost interest in my hobbies.
I feel that others do not like me.
I am unhappy with myself.
I doubt my own judgment.
I am easily frustrated.
I wish I were dead.
I feel lonely.
I avoid being around people.
My eating patterns have changed.
I have suicidal thoughts.
I deserve to be punished.
I have difficulty making decisions.
I feel emotionally shut down.
I feel worn out.
I feel worthless.
I am not interested in sex.
I feel hopeless.
I blame myself for other people’s problems.
I feel spiritually dead.
I have difficulty paying attention.
Total Scores
Total Score. . . . > >.>