CLIENT QUESTIONNAIRE
We are pleased that you have decided to make an appointment at Newark-Granville Psychological and Counseling Services. Please complete the following with as much detail as you are comfortable. If necessary, you may attach additional sheets. The information is confidential and will save time in the early appointments.
Name ______Today's Date ______
Age ______Marital Status ______Who referred you to our office? ______
Please list name, relationship, and age of other household members:
1)______
2)______
3)______
4)______
Please list all current medications, including over the counter medications and supplements:
Medication Name:______Dosage and frequency:______
Reason for medication:______How long used?______
Medication Name:______Dosage and frequency:______
Reason for medication:______How long used?______
Medication Name:______Dosage and frequency:______
Reason for medication:______How long used?______
Medication Name:______Dosage and frequency:______
Reason for medication:______How long used?______
Describe the reasons for making this appointment: ______
______
______
How long have you had these concerns? ______
What have you tried to help with these difficulties? ______
List recent stressful events: ______
______
Do you have cultural, ethnic, or religious needs that may impact treatment? ______
What are your major sources of emotional support? ______
______
______
How would you consider your present health? ______
What is the date of your last physical exam? ______List any medical problems you have encountered:
______
______
List any allergies, including medications: ______
List the date and type of in-patient and out-patient hospitalizations or surgeries you have experienced:
Date: ______Reason:______
Date: ______Reason: ______
Date: ______Reason: ______
Please list all substance abuse and mental health treatments:
Date: ______Facility: ______
Reason: ______Helpful? Yes / No
Date: ______Facility: ______
Reason: ______Helpful? Yes / No
Date: ______Facility: ______
Reason: ______Helpful? Yes / No
Please indicate your usage of the following substances:
Date last used: How often:
Alcohol ______
Marijuana ______
Tobacco ______
Cocaine ______
Caffeine ______
Ecstasy ______
Codeine ______
Steroids ______
Inhalants ______
Stimulants/Amphetamines ______
Sedatives ______
Opiates ______
Please check the following that apply to you:
___ Numbness or tingling ___Shortness of breath
___ Racing heart, palpitations ___Dizziness, blackouts
___ Nausea, diarrhea, stomach pain ___Hot flashes, chills
___ Excessive sweating, moist palms ___Feeling shaky, twitchy
___ Headaches, body aches ___Startle easily
___ Worry a lot ___Road rage
___ Lose temper easily ___Feeling edgy, restless
___ Difficulty concentrating ___Confusion, indecisiveness
___ Memory problems ___Fatigued easily
___ Difficulty sleeping ___Sleeping too much
___ Appetite low / high (circle the one that applies) ___Lost interest in usual activities
___ Feeling hopeless ___ Binge eating
___ Excessive exercise ___ Dieting
___ Self-induced vomiting ___ Using laxatives or diuretics to
___ Excessive hand washing, fear of germs lose weight
___ Excessive checking (doors, locks, etc.) ___ Excessive need for order or
___ Inability to throw things away counting things
___ Failure to complete chores or homework ___ Forgetful in day-to-day activities
___ Make careless mistakes regularly ___ Fidget a lot
___ Impulsive ___ Overspending or gambling
___ Sexual problems ___ Shame
___ Fear of criticism or fear of being embarrassed
Age of father :______(If deceased, age when died and cause of death)
Father's occupation ______
Age of mother:______(If deceased, age when died and cause of death)
Mother's occupation ______
Are/were your parents divorced? ______What age were you when they divorced? ______
Who lived in your home when you were growing up? ______
______
Did you have step-parents and/or a blended family? Please explain: ______
______
______
List all of your siblings, their ages and their occupations: ______
______
______
List any medical problems, including substance abuse and psychiatric issues that run in your family: ______
______
Briefly describe major stresses in your childhood, including exposure to violence:
______
______
Do you have a history of being abused: physical, sexual, emotional or verbal? ______
List any school concerns you had as a child, including special services, repeated grades, or behavior issues:______
Please list any marriages, and the dates of the marriages: ______
Please list any children you have and their ages: ______
______
If any significant others have died, please list them and the cause and date of their deaths:______
______
Describe your relationship with your significant other: ______
______
Highest grade or degree completed: ______
Current occupation: ______Military Service: ______
How long at your present job? ______Describe any current work concerns: ______
______
Briefly describe your work history, prior to the current position: ______
Are you currently on social media? ______How often and for how long?______
Do you participate in online gambling or playing games?______
Describe difficulties with friends, past or present: ______
______
List any legal issues you have encountered:______
______
What do you consider your greatest accomplishments? ______
______
What do you consider your greatest disappointments? ______
______
What would you like to have happen as a result of participating in counseling? ______
______
Thank you. We look forward to working with you.
Page - 1 - Adult QUESTIONNAIRE revised 10.14