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Date: ______
Patient Name: ______
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Patient Social Security Number: ____-____-____
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Date of Birth: ______
Gender Identification: ______
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Home Address:______
Home Phone Number:______May we leave a message? [ ] Yes [ ] No
Work Phone Number: ______May we leave a message? [ ] Yes [ ] No
Mobile Phone Number: ______May we leave a message? [ ] Yes [ ] No
If the above patient is a minor complete the following:
Name of Guardian: ______
Address of Guardian (if different from above): ______
Primary Contact Number: ______May we leave a message? [ ] Yes [ ] No
If you will be using insurance to reimburse your sessions or a portion of the cost please complete the following:
Primary Insurance Company: ______
Secondary Insurance Company (if applicable):______
In case of an emergency, who should we contact?
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Name: ______
Relationship: ______
Phone Number: ______
Presenting Problem and History of Symptoms
Please describe the current complaint or problem as specifically as you can, in your own words.
How long have you experienced this problem, or when did you first notice it?
What stressors may have contributed to the current complaint or problem?
Check all words/phrases that describe what you are experiencing and explain, if possible.
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[ ] Substance abuse/dependence
[ ] Addiction (please specify)______
[ ] Depression/Sad/Down feelings
[ ] High/Low energy level
[ ] Angry/Irritable
[ ] Loss of interest in activities
[ ] Difficulty enjoying things
[ ] Crying spells
[ ] Decreased motivation
[ ] Withdrawing from people/Isolation
[ ] Mood Swings
[ ] Black and white thinking/All or nothing thinking
[ ] Negative thinking
[ ] Change in weight or appetite
[ ] Change in sleeping pattern
[ ]Suicidal thoughtsor plans
[ ] Self-harm/Cutting/Burning
[ ] Homicidal thoughts or plans/Thoughts of hurting others
[ ] Poor concentration/Difficulty focusing
[ ] Feelings of hopelessness/Worthlessness
[ ] Feelings of shame or guilt
[ ] Feelings of inadequacy/Low self-esteem
[ ] Anxious/Nervous/Tense feelings
[ ]Panic attacks
[ ] Racing or scrambled thoughts
[ ] Bad or unwanted thoughts
[ ] Flashbacks/Nightmares
[ ] Muscle tensions, aches, etc.
[ ] Hearing voices/Seeing things not there
[ ] Thoughts of running away
[ ] Paranoid thoughts
[ ] Feelings of frustration
[ ] Feelings of being cheated
[ ] Perfectionism
[ ] Rituals of counting things, washing hands, checking locks, doors, stove, etc./Overly concerned about germs
[ ]Distorted body image(believe you are heavier or less attractive than others say you are)
[ ] Concerns about dieting
[ ] Feelings of loss of control over eating
[ ] Binge eating/Purging
[ ] Rules about eating/Compensating for eating
[ ] Excessive exercise
[ ] Indecisiveness about career
[ ] Job problems
[ ] Other:
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Previous Treatment
Have you received or participated in previous counseling and/or therapy? [ ] Yes [ ] No
If ‘Yes,’ Please answer the following:
** It is helpful if you can provide copies of any past documentation or reports that are relevant to the presenting problems and history that are bringing you to treatment. **
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Previous Provider(s):______
Dates of service: ______to______
Type of service(s) provided: ______
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Is there a primary care physician? [ ] Yes [ ] No
If yes, please complete the following:
Name: ______
Address: ______
Phone Number: ______
Optional:
What did you like/dislike about previous treatment?
What did you learn about yourself through previous counseling/treatment that may help you?
Is there any type of treatment you would like to continue?
Have you or your child had hospital stays for psychological concerns? [ ] Yes [ ] No
Developmental History
Are you aware of any difficulties or complications during pregnancy or birth that existed for the client?
[ ] Yes [ ] No
If yes, please explain:
Are there any developmental delays in reaching milestones in current or past history? (i.e. feeding, walking, speech, social, etc.)
[ ] Yes [ ] No
If yes, please explain:
Medical History
List any current or important past medications:
Medication & Dose: Response to Medication:
Medication & Dose: Response to Medication:
Medication & Dose: Response to Medication:
History of serious childhood illnesses (if applicable):
Please describe other health concerns, serious illnesses, conditions, or major operations requiring hospitalization during your or your child’s life time (if applicable):
Explain any allergies (if applicable):
Family History
Birth Location: ______
Raised by: [ ] Mother [ ] Father [ ] Step-Mother [ ] Step-Father [ ] Other:
Do any other children live in the home? [ ] Yes [ ] No
If yes, please complete the following:
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Name(s):______
Age(s):______
Gender(s):______
Nature of Relationship(s):______
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Are there presently any child custody issues involving you or your family? [ ] Yes [ ] No
Does your family currently have Department of Children and Families (DCF) involvement? [ ] Yes [ ] No
If yes, please complete the following:
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Case Worker’s Name:______
Phone:______
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Please briefly describe the nature of family relationships (i.e. who lives in the home?; Are there some family members who get along or seem more aligned then others? Any specific conflicts that should be addressed?)
Any history of neglect, and/or physical, verbal, emotional, spiritual, or sexual abuse?
Any family history of substance abuse, mental illness, suicide, or violence?
Social History
Describe relationships with peers and/or friends?
How would you describe your social support network?
Describe hobbies/interests:
Describe any cultural concerns:
Educational History
When attending school, client is…
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[ ] In regular classes
[ ] Home Study
[ ] Special classes
[ ] Advanced classes
[ ] Ever suspended
[ ] Placed in alternative school
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What is the highest educational level /grade completed?
Give any additional important educational information that is relevant:
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Summarize your goals for counseling/therapy:
What are your and/or your family’s strengths?
What are your and/or your family’s weaknesses?
Is there any additional information that you believe it is important for your therapist to know in order to provide you with the best care possible?
______
Signature of guardianDate
______
Signature of client Date
______
Signature of clinician Date
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