Perry Guthrie, Ph.D.
Client History
Patient/Client Name: ______Date: ______
Gender:______F______MDate of Birth: ______Age: ______
Form completed by (if someone other than client): ______
Address: ______City: ______State: ______Zip: ______
Phone (home): ______(work): ______Ext. ______
If you need any more space for any of the questions please use the back of the sheet.
Primary reason(s) for seeking services:
______Anger management ______Anxiety ______Coping ______Depression
______Eating disorder ______Fear/phobias ______Mental confusion ______Sexual concerns
______Sleeping problems _____Addictive behaviors ______Alcohol/drugs
______Other mental health concerns (specify): ______
______
Family Information
Living Living with you
Relationship Name Age Yes No Yes No
Mother______
Father______
Spouse______
Children______
______
______
Significant others (e.g., brothers, sisters, grandparents, step-relatives, half-relatives. Please specify relationship.
Living Living with you
Relationship Name Age Yes No Yes No
______
______
______
______
______
______
Marital Status (more than one answer may apply)
_____ Single_____Divorce in process _____Unmarried, living together
Length of time: _____ Length of time: _____
_____Legally married_____Separated_____Divorced
Length of time: _____Length of time:_____Length of time: _____
_____Widowed_____Annulment
Length of time: _____Length of time: _____Total number of marriages: ______
Assessment of current relationship (if applicable): _____Good _____Fair_____Poor
Parental Information
_____Parents legally married_____Mother remarried: number of times: _____
_____Parents have ever been separated_____Father remarried: number of times:_____
_____Parents ever divorced
Special circumstances (e.g., raised by person other than parents, information about spouse/children not living with you, etc.): ______
Development
Are there special, unusual, or traumatic circumstances that affected your development?
Yes_____No_____
If Yes, please describe: ______
Has there been history of child abuse? Yes_____No_____
If Yes, which type(s)? _____Sexual _____Physical_____Verbal
If Yes, the abuse was as a: _____Victim_____Perpetrator
Other childhood issues: _____Neglect_____Inadequate nutrition_____Other (please specify):
______
Comments re: childhood development: ______
Social Relationships
Check how you generally get along with other people: (check all that apply)
_____Affectionate _____Aggressive _____Avoidant _____Fight/argue often _____Follower
_____Friendly _____Leader _____Outgoing _____Shy/withdrawn _____Submissive
_____Other (specify): ______
Sexual orientation: ______Comments: ______
Sexual dysfunctions? _____Yes _____No
If Yes, describe: ______
Any current or history of being a sexual perpetrator? _____Yes _____No
If Yes, describe: ______
Cultural/Ethnic
To which cultural or ethnic group, if any, do you belong? ______
Are you experiencing any problems due to cultural or ethnic issues? _____Yes _____No
If Yes, describe: ______
Other cultural/ethnic information: ______
Spiritual/Religious
How important to you are spiritual matters? _____Not _____Little _____Moderate _____Much
Are you affiliated with a spiritual or religious group? _____Yes _____No
If Yes, describe: ______
Were you raised within a spiritual or religious group? _____Yes _____No
If Yes, describe: ______
Would you like your spiritual/religious beliefs incorporated into the counseling? _____Yes _____No
If Yes, describe: ______
Legal
Current Status
Are you involved in any active cases (traffic, civil, criminal)? _____Yes _____No
If Yes, please describe and indicate the court and hearing/trial date and charges: ______
______
Are you presently on probation or parole? _____Yes _____No
If Yes, please describe: ______
Past History
Traffic violations: _____Yes _____No DWI, DUI, etc.: _____Yes _____No
Criminal involvement: _____Yes _____No Civil involvement: _____Yes _____No
If you responded Yes to any of the above, please fill in the following information:
Charges Date Where (city) Results
______
______
______
Education
Fill in all that apply: Years of education:_____ Currently enrolled in school? _____Yes _____No
_____High school grad/GED
_____Vocational: Number of years:_____ Graduated: _____Yes _____No Major: ______
_____College: Number of years:_____ Graduated: _____Yes _____No Major: ______
_____Graduate: Number of years:_____ Graduated: _____Yes _____No Major: ______
Other training: ______
Special circumstances (e.g., learning disabilities, gifted): ______
Employment
Begin with most recent job, list job history:
Employer Dates Title Reasons left job How often miss work?
______
______
______
Currently: _____FT _____PT _____Temp _____Laid-off _____Disabled _____Retired
_____Social Security _____Student _____Other (describe)______
Military
Military experience? _____Yes _____No Combat experience? _____Yes _____No
Where: ______
Branch: ______Discharge date: ______
Date drafted: ______Type of discharge:______
Date enlisted: ______Rank at discharge: ______
Leisure/Recreational
Describe special areas of interest or hobbies (e.g., art, books, crafts, physical fitness, sports, outdoor activities, church activities, walking, exercising, diet/health, hunting, fishing, bowling, traveling, etc.)
Activity How often now? How often in the past?
______
______
______
______
Medical/Physical Health
____ AIDS____ Dizziness____Nose bleeds
____ Alcoholism____ Drug abuse____ Pneumonia
____ Abdominal pain____ Epilepsy____ Rheumatic Fever
____ Abortion____ Ear infections____ Sexually transmitted diseases
____ Allergies____ Eating problems____ Sleeping disorders
____ Anemia____ Fainting____ Sore throat
____ Appendicitis____ Fatigue____ Scarlet fever
____ Arthritis____ Frequent urination____ Sinusitis
____ Asthma____ Headaches____ Smallpox
____ Bronchitis____ Hearing problems____ Stroke
____ Bed wetting____ Hepatitis____ Sexual problems
____ Cancer____ High blood pressure____ Tonsillitis
____ Chest pain____ Kidney problems____ Tuberculosis
____ Chronic pain____ Measles____ Toothache
____ Colds/Coughs____ Mononucleosis____ Thyroid problems
____ Constipation____ Mumps____ Vision problems
____ Chicken Pox____ Menstrual pain____ Vomiting
____ Dental problems____ Miscarriages____ Whooping cough
____ Diabetes____ Neurological disorders____ Other (describe): ______
____ Diarrhea____ Nausea______
List any current health concerns: ______
List any recent health or physical changes:______
______
Nutrition
Meal How often Typical foods eaten Typical amount eaten f
(times per week)
Breakfast____ / week______No ____Low ____ Med ____ High
Lunch____ / week______No ____Low ____ Med ____ High
Dinner____ / week______No ____Low ____ Med ____ High
Snacks____ / week______No ____Low ____ Med ____ High
Comments: ______
Current prescribed medications Dose Dates Purpose Side Effects
______
______
______
______
Current over-the-counter meds Dose Dates Purpose Side Effects
______
______
______
______
Are you allergic to any medications or drugs? _____Yes _____No
If Yes, describe: ______
Date Reason Results f
Last physical exam______
Last doctor’s visit______
Last dental exam______
Most recent surgery______
Other surgery______
Upcoming surgery______
Family history of medical problems:______
Please check if there have been recent changes in the following:
____Sleep patterns ____Eating patterns ____Behavior ____Energy level
____Physical activity level ____General disposition ____Weight ____Nervousness/tension
Describe changes in areas in which you checked above:______
______
Chemical Use History
Method of Use & Frequency of Age of Age of Used in the Used in the
AmountUse 1st Use Last Use last 48 hrs? last 30 days?
Y N Y N
Alcohol______
Barbiturates______
Valium/Librium______
Cocaine/Crack______
Heroin/Opiates______
Marijuana______
PCP/LSD/
Mescaline______
Inhalants______
Caffeine______
Nicotine______
Over the counter______
Prescription drugs______
Other drugs______
Substance of preference
1. ______3. ______
2. ______4. ______
Substance Abuse Questions
Describe when and where you typically use substances:______
______
Describe any changes in your use patterns: ______
______
Describe how your use affected your family or friends (include their perceptions of your use):______
______
Reason(s) for use:
____Addicted ____Build confidence ____Escape ____Self-medication
____Socialization____Taste____Other (specify): ______
How do you believe your substance use affects your life? ______
Who or what has helped you in stopping or limiting your use?______
Does/has someone in your family present/past have/had a problem with drugs or alcohol? ____Yes
____No If Yes, describe: ______
Have you had withdrawal symptoms when trying to stop using drugs or alcohol? ____Yes ____No
If Yes, describe:______
Have you had adverse reactions or overdose to drugs or alcohol? If Yes, describe: ______
______
Does your body temperature change when you drink? ____Yes ____No
If Yes, describe: ______
Have drugs or alcohol created a problem for your job? ____Yes ____No
If Yes, describe:______
Counseling/Prior Treatment History
Information about client (past and present):
Your reaction
Yes No When Whereto overall experience
Counseling/Psychiatric
Treatment______
Suicidal thoughts/
Attempts______
Drug/alcohol treatment______
Hospitalizations______
Involvement with self-help
groups (e.g., AA, Al-Anon
NA, Overeaters Anonymous)______
Information about family/significant others (past and present):
Your reaction
Yes No When Whereto overall experience
Counseling/Psychiatric
Treatment______
Suicidal thoughts/
Attempts______
Drug/alcohol treatment______
Hospitalizations______
Involvement with self-help
groups (e.g., AA, Al-Anon
NA, Overeaters Anonymous)______
Please check behaviors and symptoms that occur to you more often than you would like them to take place:
____ Aggression____ Elevated mood____ Phobias/fears
____ Alcohol dependence____ Fatigue____ Recurring thoughts
____ Anger____ Gambling____ Sexual addiction
____ Antisocial behavior____ Hallucinations____ Sexual difficulties
____ Anxiety____ Heart palpitations____ Sick often
____ Avoiding people____ High blood pressure____ Sleeping problems
____ Chest pain____ Hopelessness____ Speech problems
____ Cyber addiction____ Impulsivity____ Suicidal thoughts
____ Depression____ Irritability____ Thoughts disorganized
____ Disorientation____ Judgment errors____ Trembling
____ Distractibility____ Loneliness____ Withdrawing
____ Dizziness____ Memory impairment____ Worrying
____ Drug dependence____ Mood shifts____ Other (specify):
____ Eating disorder____ Panic attacks______
Briefly discuss how the above symptoms impair your ability to function effectively:
______
______
______
______
______
______
______
______
______
Any additional information that would assist us in understanding your concerns or problems:
______
______
______
______
______
______
______
______
What are your goals for therapy?
______
______
______
______
______
______
______
Do you feel suicidal at this time? _____Yes _____No
If Yes, explain: ______
______
______
______
Therapist’s signature/credentials: Date:
______