Name(Last, First, M.I.): / DOB: / Age:
Former Name(s) / Social Security Number:
Street Address:
City: / County: / State: / Zip Code: / Email:
Telephone / Home:Cell:Work:
Marital status:
/ Single Domestic Partner Married Separated Divorced WidowedDo you have children under 18 years of age?
Yes No Unknown / Children age range(s)? (If under 18 years of age)0-5 6-11
12-17 Unknown / Children residing with client?
(If under 18 years of age)
Full-time Part-time
Not at all Unknown / Children have special needs?
Yes No Unknown
LIVING STATUS
Living Status:
/Homeless Foster Care / Foster Home Residential Care Crisis Residence Institutional Setting
Jail / Correctional Facility Private Residence – Independent Living Private Residence – Dependent Living
Other Residential Status Board and Lodge Nursing Facility, including boarding care HospitalRegional Treatment Center Children’s Residential Treatment Facility Detox and / or Withdrawal Management Facility
Unknown
Housing Status:
/Homeless At imminent risk of homelessness Chronically homeless Housed Unknown
At this time:
/Person is wanting or planning to move from current environment
Not wanting or planning to move from current environmentHousing Preferences / Needs (if moving or planning to move)
/None / Prefers not to share Accessibility to home and all areas of home Have a pet
Accommodates desired routines and preferred schedule Accommodates my cultural preferences or needs
Alcohol and/or tobacco use Availability of public transportation Location – concerns for personal safety
Location – to family and friends Location – to leisure / entertainment activities Roommate (s)Location – to shopping, school, doctors, etc. Location – to work or jobs Own apartment / home
Space / room for caregiver Other Unknown
Barriers to Moving: (Please answer this if you are planning or wanting to move)
None Can’t meet income requirements Concerns for health & safety by legal representative or team Credit history Criminal historyDrug / Alcohol use History of evictions or Unlawful Detainers Lack of affordable housing Lack of rental history
Needs housing access assistance Personal safety concerns related to available locations Security deposit / first month’s rent
Tobacco use Transportation access / public transportation Other:______Unknown
DEMOGRAPHICS
Reside on a Reservation:
/No- Does not reside on a Reservation Bois Forte Fond-du-Lac Grand-Portage Leech Lake Lower Sioux Mille-Lacs Band Prairie Island Red Lake Shakopee Upper Sioux White Earth Other Unknown
Tribe Enrollment:
/Not Enrolled Unknown Bois Forte Fond-du-Lac Grand-Portage Leech Lake Lower Sioux
Mille-Lacs Band Prairie Island Red Lake Shakopee Upper Sioux White Earth Other
Race:
/American Indian or Alaska Native Asian Native Hawaiian or other Pacific Islander African American or Black
Caucasian or White Some other Race Alone UnknownEthnicity:
/Not of Hispanic Origin Puerto Rican Mexican Cuban Other Specific Hispanic
Hispanic Origin regardless of race Unknown
Preferred Language:
/English Spanish Hmong Mandarin Other (Please specify) ______
Tobacco Use
/No Tobacco use Ongoing Tobacco use Unknown
Type of tobacco usage:
/Smoke Chew E-cig Vape
GENDER IDENTITY
Gender:
/Female Male Choose not to disclose
Birth Gender:
/Female Male Unknown Choose not to disclose
Gender Identity:
/Identifies as Female Identifies as Male Genderqueer, neither exclusively male nor female
Male–to–Female (MTF) / Transgender Female/Trans Woman Female–to–male (FTM) / Transgender Male/Trans ManAdditional gender category or other, Please specify: ______ Choose not to disclose
Sexual Orientation:
/Straight or Heterosexual Lesbian, Gay or Homosexual Bi-Sexual Don’t know
Something else, Please describe:______Choose not to discloseEDUCATION
Highest level
of Education: / 1st grade 2nd grade 3rd grade 4th grade 5th grade 6th grade 7th grade 8th grade 9th grade 10th grade
11th grade 12th grade GED Vocational / Tech School 1st year college 2nd year college 3rd year college 4th year college
Graduate / Professional / Master’s Degree (law, medical, etc.)
Current Education Enrollment Status: Enrolled Not Enrolled
MILITARY / VETERAN STATUS
Military / Veteran Status:
/ Yes / Prior military / Veteran Active duty military Served in a combat zoneNo combat zone Combat unknown
Served from:______to ______Deployment from: ______to ______
No Unknown
Is Veteran receiving VA Mental Health Services? (Please answer if you are Active Military or Prior Military/Veteran status)
Yes No Unknown
LEGAL STATUS
Voluntary – Self Voluntary – Other (guardian, parent) Court Hold Emergency Hold Civil Commitment MI Civil Commitment MI/CD Unknown
Civil Commitment MI/DD Civil Commitment MI & D Civil Commitment – sexual Civil Commitment – other Criminal Commitment Provisional Discharge
EMLOYMENT STATUS
Employment Status:
/ Employed full time (≥32 hours/week)Employed part time (≤32 hours/week)
Look for work / Unemployed
Crew / Enclave / Group Employment
Self – employed Sheltered employment / Place of employment:______
Occupation:______
Clerical Labor Professional Unknown
Employment Type:
/ Currently working in non-competitive job and interested in exploring competitive options.Currently working in competitive job and interested in exploring other competitive options.
Currently working in competitive job and seeking no changes.
Currently working in non-competitive job and seeking no changes.
Rate satisfaction with current hours:
DissatisfiedNeither dissatisfied or satisfied
Satisfied / Rate satisfaction with current pay:
Dissatisfied
Neither dissatisfied or satisfied
Satisfied / Rate satisfaction with current type of work:
Dissatisfied
Neither dissatisfied or satisfied
Satisfied
Competitive Work Concerns or Perceived Barriers:
/ None Chooses not to answer Retired/approaching retirement Impact on disability benefits TransportationSafety or vulnerability in the community Lack of service, supports or resources Intermittent health crisis or needs
Limited skills Limited experiences with work; uncertainty about what is possible Impact on caregivers
Criminal history Unstable housing No longer interested in work due to negative experiences Other Unknown
Not in the Labor Force:
/ Not working or looking for employment Homemaker Student Retired Disabled Not applicableHospital patient or resident of other institutions Other reported classification (Volunteers) Unknown (HWS only)
HEALTHCARE PROVIDER INFORMATION
Do you have a regular physician? Yes No / Provider/Facility name:______Phone:______
Address:______
Do you have a regular dentist? Yes No / Provider/Facility name:______Phone:______
Address:______
Do you currently access any other agencies and/or services? Yes No
(Case Manager, guardian, ARMHS providers, public health, home health) / Provider/Facility name:______Phone:______
Address:______
Do you want a summary sent to this person? Yes No
Were you referred here by someone? Yes No / Who sent you? ______
Address:______
Do you want a summary sent to this person? Yes No
What are the major concerns, issues or symptoms that bring you to our center?
List any previous mental health therapy you have had.
GOALS OF THERPAY
What goals do you have for your treatment?
ALLERGIES
Have you ever had allergic reactions to medications:
Hives, skin rash, breathing problems or other? Yes No / If yes, please list the medication and reaction:
Are there medications, other than those you are allergic to, you would prefer not to take due to unpleasant side effects? Yes No
If yes, please specify which medication and what the unpleasant side effect was:
GENERAL MEDICAL
When did you last have a medical checkup? Date:______Primary Provider Name:______
Have you ever had any of the following problems? Please circle any problems you have had: / Seizure Diabetes Head Injury Asthma High Blood Pressure
Heart Trouble Liver Problems Kidney Problems High Cholesterol Thyroid Problems
Other
Have you ever had any surgery or medical hospitalizations? Yes No / If yes, please list the date and procedure/reason you were hospitalized:
Have you ever been hospitalized for mental health reasons? Yes No / If yes, please list the date reason you were hospitalized:
Are you currently taking any prescription medication? Yes No / If yes, please list the medication and the dosage below:
Name and location of pharmacy
Have you taken steroid or cortisone-type drugs within the last year? Yes No
Have you taken any over-the-counter meds, herbal remedies or supplements in the last month? Yes No
Please list:
Have you ever been on medications (other than those listed above) for “nerves”, depression, anxiety, or other psychological issues? Yes No / If yes, Please list:
If sexually active, do you use any contraceptives or protection from sexually transmitted diseases (STD’s)? Please specify:
FAMILY RELATIONSHIPS
If you are in a relationship, please complete: Partner’s name:______How long in relationship:______
Please list all people with whom you currently live with: / Name(s) / Age(s) / Relationship to person receiving services
Please list parents, brothers, sisters, minors, or adult children who are not currently living in your home: / Name(s) / Age(s) / Relationship to person receiving services
Are you adopted? Yes No
Please describe any family information (current/past) that might be helpful:
- Mental health illness
- Medical issues
- Deaths in the family
- Divorces, step-parents
- Any type of abuse/trauma
Are you currently religiously affiliated? Yes No Decline / If yes, what religion?
Former religious affiliation? / Yes No Decline If yes, what religion?
PLEASE CONTINUE ON THE NEXT PAGE
CHEMICAL and ALCOHOL USE
Drug Use
(Check your drug of choice, if applicable) / Age of First Use / Most Recent Pattern of use and Duration
How much you use, how often, and do you need more or less to get the same effect? / Date of last use and time, if needed / Method of use:
(Oral, smoked, snort, iv, etc.)
ALCOHOL
CAFFEINE
MARIJUANA / HASHISH
COCAINE / CRACK
METH / AMPHETAMINES
HERION
SYNTHETICS
INHALANTS
BENZODIAZEPINES
HALLUCINOGENS
BARBITURATES / SEDATIVES / HYPNOTICS
OVER-THE-COUNTER MEDICATIONS
NICOTINE
OTHER
Do you use greater amounts of alcohol/other drugs to feel intoxicated or achieve the desired effect? Yes No
Or use the same amount and get less of an effect? Yes No
Have you ever been to detox?
Yes No / When was the first time? / How many times since then? / Date of most recent detox?
WITHDRAWAL SYMPTOMS; HAVE YOU HAD ANY OF THE FOLLOWING WITHDRAWAL SYMPTOMS?
SYMPTOM / PAST 12 MONTHS / RECENT
(PAST 30 DAYS) / SYMPTOM / PAST 12 MONTHS / RECENT
(PAST 30 DAYS)
SWEATING (RAPID PULSE) / NAUSEA/VOMITING
SHAKEY/JITTERY/TREMORS / DIZZINESS
UNABLE TO SLEEP / SEIZURES
AGITATIONS / DIARRHEA
HEADACHE / DIMINISHED APPETITE
FATIGUE/EXTREMELY TIRED / HALLUCINATIONS
SAD/DEPRESSED FEELING / FEVER
MUSCLE ACHES / UNABLE TO EAT
VIVID/UNPLEASANT DREAMS / PSYCHOSIS
IRRITABILITY / CONFUSED/DISRUPTED SPEECH
SENSITIVITY TO NOISE / ANXIETY
HIGH BLOOD PRESSURE / WORRIED
Are you seriously considering addressing your alcohol and/or drug use within the next six months? Yes No
Are you planning to stop or reduce your alcohol and/or drug use within the next 30 days? Yes No
(Perhaps taking small steps to do so)?
Are you now actively remaining abstinent from your use of alcohol and/or drugs? Yes No
Have you ever felt you ought to cut down on your drinking or drug use? Yes No
Have you ever had people annoy you by criticizing your drinking or drug use? Yes No
Have you ever felt bad or guilty about your drinking or drug use? Yes No
Have you ever had a drink or used drugs as an eye opener first thing in the morning to steady your nerves, to get rid of a hangover, or to get the day started? Yes No
REASONS FOR DRINKING/DRUG USE (CHECK ALL THAT APPY)
Like the feeling / To relax or unwind / Partner encourages use / Trying to forget problems
Makes it easier to talk with people / Most friends drink or use / To cope with stress / To cope with family problems
To relieve physical pain / To cope with anxiety / To cope with depression / Other (please specify)
Have you ever been to an AA/NA or any other 12-step Support Group? Yes No If yes, date of last meeting______
Do you have a sponsor? Yes No
Any history of suicide in your family? Yes No Or, someone close to you? Yes No
Are thoughts of suicide occurring when under the influence? Yes No
Please list any current/recent history of legal problems related to substance use:
______
Signature of Person Completing Form & Relationship to ClientDate
Thank you for taking the time to fill out this form as it will help us to better understand you and your situation.