Identifying Information (To Be Filled out by the Person Requesting Services)

ADULT APPLICATION FOR SERVICES

Name:______Address:______

FirstMiddleLastStreetCityState Zip Code

County:______Phone:______

HomeWorkCell

Social Security Number:______Date of Birth:______Age:_____ Male / Female Race:______

Do you have health Insurance: Yes / NoWho referred you for services?______

Do you receive (check all that apply): ____Medicaid ____Medicare ____VA Benefits ____Food Stamps ____WIC ____SSDI ____Energy Assistance ____Subsidized Housing ____None of the above

Primary Language:_____English _____Spanish _____Other:______

Are you: ______Married ______Single ______Separated _____Divorced ____Widowed ____Live with significant other

Legal Status: Are you your own guardian/payee? Yes / NoIf no, are you a minor? Yes / NoOther:______

My guardian/Payee is:______

NameRelationshipPhone

______

Street AddressCityState Zip Code

Emergency Contact:______

NameRelationshipPhone

______

Street AddressCityState Zip Code

Presenting Problem:

Why have you come here today and what do you feel is your main concern?______

______

How has this concern caused problems in your life?______

Did you just start having problems? _____Yes_____No

If no how long have you had these problem(s)?

Do your problems interfere with your daily life? _____Yes_____No

Have you ever had thoughts of hurting yourself? _____Yes_____No

Have you ever made any suicide attempts? _____Yes_____No

Do you have current thoughts of hurting yourself? _____Yes_____No

Have you ever been hospitalized for suicide thoughts/attempts? _____Yes_____NoIf yes, when?______

Have you ever had thoughts of hurting someone else? _____Yes_____No

Do you have current thoughts of hurting someone? _____Yes_____No

Do you feel you are in danger now? _____Yes_____No

Are you involved in a gang? _____Yes_____No

Are you in a domestic violence situation? _____Yes_____No

Are you in an elder abuse situation? _____Yes_____No

Are you in any other dangerous situation? _____Yes_____NoIf yes, please explain:______

Do you have enough food to eat? _____Yes _____No

Do you believe you need medications? _____Yes______No

What are your goals (check all that apply)?

_____To become independent _____To have less hospitalizations ____To stay out of jail ____To learn job skills ____To learn to drive _____To manage my symptoms _____To work part-time _____To learn to handle money _____To get a GED/high school diploma _____To stay off of drugs and/or alcohol ____Other (please explain):______

What are your strengths (check all that apply)?

_____I have a supportive family _____I have a supportive boss _____I desire help _____I have supportive friends _____I am drug free

_____I’m in good health _____I’m trustworthy _____I take pride in my appearance _____I have self-respect

____Other (please explain):______

What are your attributes (check all that apply)?

_____I will ask for help _____I can concentrate _____I follow rules _____I can read and write _____I am dependable

_____I take my medications _____I can provide for my needs of daily living ____I am hardworking

_____Other (please explain):______

Do you have any special needs? Yes / NoIf yes, please explain:______

Support Contact:______

NameRelationshipPhone

______

Street AddressCityState Zip Code

What is your current living situation?

_____With my parents _____In a foster home _____With my spouse/children _____Homeless _____Non-relative roommate

_____With a relative _____Alone _____In a group home _____In a residential care facility _____Incarcerated

Do you have problems with the home you live in? _____Yes _____No

Is your living situation okay? _____Yes _____No

Family Situation:

Are you married? _____Yes _____No

Do you have a significant other? _____Yes _____No

How many times have you been married?______

Do you have children? _____Yes _____No

Do you have a good relationship with your children? _____Yes _____No

Do your children live with you? _____Yes _____No

Are they in foster care? _____Yes _____No

Do you have any deceased children? _____Yes _____No

Please list your children’s names and ages:

______

NameAgeNameAgeNameAge

______

NameAgeNameAgeNameAge

Will anyone in your family come in for sessions with you? Yes / NoIf yes, who?______

Are any of these problems in your family now (check all that apply)?

_____Physical abuse _____Emotional abuse _____Neglect _____Sexual abuse _____Children removed from the home

_____Conflict due to divorce _____Domestic violence _____Substance abuse

Are you a victim of these problems? _____Yes _____No

Are you abusing anyone physically or emotionally? _____Yes _____No

Childhood History:

Were your parents married? _____Yes _____No

Were your parents divorced? _____Yes _____No

Were your parents separated? _____Yes ______No

Did you experience any of the following problems during your childhood (check all that apply): ___Children removed from the home ___Physical abuse ___Sexual abuse ___Neglect ___Emotional abuse ___Alcohol abuse ___Drug abuse ___Other (please explain):______

Did you abuse anyone while growing up? _____Yes _____No

Did you ever hurt animals? _____Yes ___No

Was anyone in your family mentally ill? ____Yes ____No

If yes, who: ___Mother ___Father ___Sibling ___Grandparent ___Aunt/uncle

If yes, what was their diagnosis?______

Educational History:

What type of education do you have? ____Graduated from high school ____GED _____Vocational training _____Attended college

Do you have a degree? _____Yes _____NoIf yes, what type of degree? ____Associates ____Bachelor’s ____Master’s ____PhD

Employment History:

Are you currently employed? _____Yes _____No

If unemployed, for how long?______

Are you looking for a job now? _____Yes_____No

If yes, do you work:___full-time ___part-timeFor how long?______Where do you work?______

Where did you work before?______What job interests do you have?______

Did you ever have any of the following problems? _____Absences _____Tardy _____Lay offs _____Repeated firings

_____Getting along with the boss ____Getting along with co-workers

Spiritual:

Are you involved in spiritual activities? _____Yes ___No

Cultural:

Check all that is important for your counselor to understand about you:

____Sexual orientation ____Specific cultural beliefs ____Spiritual ____Religious ____Gender specific _____Language _____Economic

Recreational:

What recreational activities do you like to do (check all that apply)?

____Arts and crafts ____Reading ____Sports ____Television ____Video games ____Computer ____Church ____Pets

____Cars/Motorcycles ____Exercise ____Self-help ____Spiritual based _____Other (please explain):______

Military:

Have you ever been in the military? _____Yes _____NoIf yes, what branch of the military?______

Are you active? _____Yes _____NoIn the Reserves? _____Yes _____No

Dates of Service:______

Did you have any problems in the service? _____Yes _____NoIf yes, please explain:______

Social Problems:

Do you have any of the following social and/or daily living problems (check all that apply):

____Difficulty making friends ____Low self-esteem ____Shy/low confidence ____Do not like to be around a lot of people

____Aggressive behaviors ____Poor hygiene ____Difficulty handling money ____Cooking ____Cleaning ____Poor decision making

____Getting help in the community ____Other (pleaseexplain):______

Legal History:

Are you a victim of a violent crime? _____Yes _____NoHave you ever been arrested? _____Yes _____No

Have you ever been charged with a crime? _____Yes _____NoAre you ever been on Probation? _____Yes _____No

Have you ever been on Parole? _____Yes _____NoHave you ever had a DUI? _____Yes _____No

Alcohol/Drug History:

Do you use drugs or alcohol? _____Yes_____NoIf yes, please explain:

______

Drug NameAge First UsedHow UsedAmount UsedHow oftenCurrently Use (yes/no)

______

Drug NameAge First UsedHow UsedAmount UsedHow oftenCurrently Use (yes/no)

______

Drug NameAge First UsedHow UsedAmount UsedHow oftencurrently Use (yes/no)

If you no longer use drugs or alcohol, how long has it been since you used?______

Have you ever not remembered parts of the day or evening after you drank? _____Yes_____No

Have you ever drank or used more than you wanted to? _____Yes_____No

Has anyone ever said you need to quit drinking or using drugs? _____Yes_____No

Does anyone in your family currently drink or use drugs? _____Yes_____No

Did your mother use alcohol, drugs or tobacco during her pregnancy with you? _____Yes_____No

Do you smoke? _____Yes_____NoIf yes, how many packs per day?______

Psychiatric History:

When was your last psychiatric evaluation?______

Do you have any of the following emotional problems (check all that apply): ____Fears ____Feeling like a failure ____Lonely ____Guilt ____Depressed ____Anxious ____Sexual problems ____Hearing voices/noises ____Suicidal thoughts ____Racing thoughts ____Too much energy ____Concentration ____Poor appetite ____Other (please explain):______

Have you ever had a psychiatric hospitalization? _____Yes_____NoIf yes, please explain below:

______

Reason for HospitalizationDateReason for HospitalizationDateReason for HospitalizationDate

Medical History:

When was your last physical exam?______

Who is your medical doctor?

______

NamePhoneAddressCityStateZip Code

Do you have any of the following medical problems (check all that apply): ____High blood pressure ____Diabetes _____Breathing ____Thyroid disease ____Cancer ____Arthritis ____Seizures ____Blood in stool/urine ____Heart disease ____Numbness ____Coughing blood ____Weight loss ____Tired ____Rapid heart beat ____PMS/Menstrual ____Other (please explain):______

Have you ever had a medical hospitalization? Yes / NoIf yes, please explain below:

______

Reason for HospitalizationDateReason for HospitalizationDateReason for HospitalizationDate

Have you ever had any visual, hearing or physical impairment screenings? _____Yes_____No

Do you have any physical limitations or restrictions? _____Yes_____No

If you are a minor, are your immunizations current? _____Yes_____No

Do you have any allergies or reactions to any medications? _____Yes_____No

If yes, which ones?______

Do you have any other allergies? _____Yes_____NoIf yes, please explain:______

Medications:

Do you currently take any medications? _____Yes_____NoIf yes, please list below (prescribed and over-the-counter):

______