Kelley Therapeutic Services, LLC—Lisa Kelley MSW LCSW
5400 Laurel Springs Parkway Suite 1101 Suwanee, GA 30024 678-90-5543
Client Self Report-Adult
Today’s Date:
Client Name: Age: Date of Birth:
- Briefly describe the issue that brings you here today:
- What do you want to see changed:
- What kind of help do you want from Kelley Therapeutic Services:
Check below any behaviors/symptoms issues the client has difficulty with:
ADHDDepressionAnxiety
hyperactivesadexcessive worry
impulsivesleep problemspanic attacks
underachievementnegative thinkingirrational fear
non-compliantpoor concentrationobsessions
inattentivehopeless/worthlesssocial isolation
poor concentrationmood swingsphobias
disorganizedguiltcompulsions
RelationshipAngerAddictions
marital/significant othershort fusedalcohol
parentingtemper tantrumsdrugs
difficulty with friendsimpulse controlgambling
work/school problemsviolent/assaultiverelationships/sex
personal growthrunaway riskeating disorders
grief/lossfightingcyber/internet
bullying/teasingirritablespending
oppositional
AbuseOther
physicalagitated
emotionalmania
domestic violenceparanoia
rapedelusions
sexualtics/tourettes
dissociativecutting behavior
appetite changes
nightmares/flashbacks
eating disorders
- Are you now or have you ever had thoughts of hurting yourself or someone else? Yes No
If yes please describe.
Psychiatric Treatment
- Have you ever been treated for psychiatric, substance abuse, emotional or behavioral problems in the past? Yes No
If yes when, where and with whom?
Provider Name:
counselorpsychiatristpsychologistsubstance abuse counselor
Psychiatric medications currently taking and effectiveness:
- Did you find past treatment helpful? YesN o
If yes, how?
If no, why not?
- Please list any medications given:
- Are you currently under the care of a psychiatrist or therapist for your current problem? YesNo
- Are you currently taking any medications for psychiatric problems? YesNo
If yes, please list:
Medical Issues
- Does you have any current medical problems or health issues? YesNo
If yes please list:
- When was the last time you were seen by a doctor?
- Would you like information from today’s visit communicated with your doctor? YesNo
- Are you currently taking medications for medical issues?YesNo
If yes please list:
- Are there any allergies and/or medication allergies?YesNo
If yes please list:
- Is there any history of head injury, seizures, loss of consciousness, or extended high fevers? Yes No If yes please list:
- (Women only) Are you pregnant? YesNo
- Do you have pain management issues? YesNo
Substance Use/Abuse
- Have you been treated for drugs, alcohol, or other addictions?YesNo
- Do you currently attend support groups?YesNo
- Does anyone in your household have problems with drugs, alcohol, or other addictions? Yes No
- Check any of the following you have used in the past 30 days:
alcoholmarijuanatranquilizerssleeping pills
pain killersheroincocaine/crackamphetamines/speed
methadoneLSDPCPecstasyinhalants
- Have you experienced withdrawal symptoms? YesNo
If yes check all that apply:
withdrawalheadachesnauseavomitingtremors
seeing thingshearing thingsintoxicated
- Have you ever had a DUI/DWI? YesNo
Legal Issues
- Do you have current legal issues?YesNo
If yes please list:
- Are you currently on probation or parole?YesNo
- Are there any legal issues such as:
- divorce in process
- possible custody battle
- going to court
- other:
- Is a DFACS worker involved?YesNo
Educational/Work Issues
- Check current employment status: Full Part Time Unemployeed Homemaker Student Disabled Retired
- Are you currently on leave from work or seeking medical leave/disability? Yes No
If yes, do you have paperwork that needs completing? Yes No
- Check educational background: Current student Did not complete high school High school graduate GED Some college Associates degree Undergraduate degree Advanced degree
- Did you experience difficulties in school? Yes No
Family/Relationships
- Please list anyone who lives in the home, his/her age, and relationship:
- Does anyone in the immediate family have psychiatric, emotional, substance abuse, or behavioral problems? Yes No
If so please describe:
- Is your immediate family supportive of you seeking treatment?YesNo
- Does anyone in your extended family have psychiatric, emotional, substance abuse, or behavioral problems? Yes No
If yes, please describe:
- Do you have any domestic violence history or current issues? Yes No
- Do you have any history of sexual and/or physical abuse? Yes No
- Please rate your support network (i.e. friends, family, neighbors, religious organizations, etc): good fair poor
- List any spiritual/cultural/ethnic considerations that could impact therapy:
- List your strengths/resources and hobbies/interests:
- Do you have difficulties or concerns about how you get along with other people? Yes No
- Are you having difficulty with spiritual or religious matters? Yes No
- Do you have any sexual orientation/gender issues or concerns? Yes No
Treatment Access/Mobility
- Are there any financial concerns that would affect your ability to access treatment? Yes No
- Do you have access to transportation?YesNo
- Do you have any disabilities, special needs, or other restrictions that may impact treatment or access to treatment? Yes No
Client (or person completing this form) signatureDate
Therapist signature/credentialsDate