Current Occupation(s)__________________________________________________________________
Are you in counseling now? Yes___ No___ If yes, with whom________________________________
Name of medical doctor(s)_______________________________________________________________
Office locations(s)______________________________________________________________________
When was your last medical exam?_______Explain the circumstances/outcome of the exam___________
Are you currently on medications? Yes_____ No_____ If yes, for what reason?____________________
Medication prescribed by: Psychiatrist_____ Other Medical Doctor_____
Name of Medications(s): _______________________________________________________________
Dosage(s)____________________________________________________________________________
Please name any drug, food or environmental allergies_________________________________________
Person to contact in case of emergency___________________Telephone___________Relationship_____
By whom were you referred_______________________________________________________________
_____________________________________________________________________________________
PROBLEM AREAS
Not a Mild Moderate Severe
Please check your response Problem Problem Problem Problem
1. Financial Problems ___ ___ ___ ___ Rate your overall
2. Physical health and/or handicap ___ ___ ___ ___ level of distress
3. Misuse of drugs or alcohol ___ ___ ___ ___
4. Spiritual concerns ___ ___ ___ ___ ___mild
5. Sexual concerns ___ ___ ___ ___ ___moderate
6. Problems between parents/children ___ ___ ___ ___ ___severe
7. Physical abuse/violence ___ ___ ___ ___
8. Problems with aging ___ ___ ___ ___ How long have
9. Communication problems ___ ___ ___ ___ been experiencing
10. Problems with pregnancy ___ ___ ___ ___ these problems?
11. Separation or divorces ___ ___ ___ ___
12. Problems between husband/wife ___ ___ ___ ___ ___under 3 months
13. Trouble relating to others ___ ___ ___ ___ ___3-6 months
14. Career problems ___ ___ ___ ___ ___6-12 months
15. Legal difficulties ___ ___ ___ ___ ___1-2 years
16. Lack of self esteem ___ ___ ___ ___ ___3-4 years
17. Food/body image problems ___ ___ ___ ___ ___5 or more years
18. Other_______________ ___ ___ ___ ___
________________________________________________________________________________________
CURRENT HISTORY
Are you feeling suicidal? ___Yes ___No Have you ever had suicidal thoughts? ___Yes ___No If yes, when____________________________Have you ever made a plan to commit suicide? ___Yes ___No If yes, please explain________________________________________________________________________
Have you ever attempted suicide? ___Yes ___No If yes, state when and what happened___________
______________________________What led you to decide to seek therapy?______________________________________________________________________________________What do you hope to gain from therapy?____________________________________________________________
Is there anything that might get in the way of your work here?____________________________________________
____________________________________________________________________________________________
How satisfied are you with:
a) Your work career?___________________________________________________________________________
b) your social life/friendships?____________________________________________________________________
c) your intimate life (spouse/lover)________________________________________________________________
d) your sexuality?_____________________________________________________________________________
WHAT SYMPTOMS HAVE YOU BEEN FEELING (PLEASE CHECK)?
___ Numb ___ Used/Put Upon ___ Headaches
___ Depressed ___ Embarrassed ___ Worry
___ Hopeless ___ Shameful/Inadequate ___ Racing Thoughts/Obsessive Thoughts
___ Confused ___ Lonely ___ Compulsive Behaviors (specificy)___
___ Disappointed/Let Down ___ Guilty ______________________________
___ Empty ___ Trapped ___ Weight Gain
___ Sad ___ Fatigue ___ Weight Loss
___ Fearful ___ “Wired”/Unable to SlowDown ___ Memory Impairment
___ Panic Attacks ___ Sleep Problems: ___ Trouble Concentrating
___ Anxiety ___ Too much sleep
___ Nervousness ___ Not enough sleep/ ___ Hallucinations (sound/sight/touch)
___ Tense interrupted sleep ___ Other__________________________
___ Angry ___ Nightmares _______________________________
___ Hostile/Violent ___ Flashbacks
___ Resentful
HOW LONG HAVE YOU BEEN EXPERIENCING THESE SYMPTOMS/FEELINGS?
___Under 3 months ___6 - 12 months ___ 3 - 4 years ___ All my life
___ 3 - 6 months ___1 - 2 years ___5 or more years
____________________________________________________________________________________________
BACKGROUND
IDENTIFY AREAS OF CONCERN THAT APPLY TO YOU OR A FAMILY MEMBER
1. Check box to indicate yourself 2. Write in mother, father, brother, sister, spouse, lover, etc in space provided
Food/Eating Disorders
___ Compulsive eater___________________ ___ Exercise_______________________________
___ Bulemic___________________________ ___ Sexuality______________________________
___ Anorexia__________________________ ___ Infidelity______________________________
___ Smoker___________________________ ___ Emotionally Abusive_____________________
___ Alcohol Use_______________________ ___ Physically Abusive_______________________
___ Other Drug Use____________________ ___ Anxiety/Panic Attacks____________________
___ Religion__________________________ ___ Depression/Sadness______________________
___ Work Habits______________________
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___ Perfectionism ___ Chronic Physical Illness/Diagnosis_________________
___ Compulsive Gambling_____________ ___ Compulsions/Obsessions What? __________________
___ Other___________________________ ___ Excessive Spending_____________________________
Location(s) while growing up: ___________________________________________________________________
Education: ___Some High School ___High School Graduate ___Post High School ___College ___Graduate Work
Religion while growing up: ___None ___Jewish ___Protestant ___Catholic ___Other Now?___________
Would you describe yourself as a child and adolescent_________________________________________________
____________________________________________________________________________________________
Who raised you as a child/adolescent?________________Were your parents separated or divorced ___Yes ___ No
How many brothers an sisters do you have?__________________________________________________________
What number child are you? ____Only ___First ___Second ___Third __________________________
Have any of your family members died? ___Yes ___No If yes, who and when?________________________
How were you disciplined as a child/adolescent?______________________________________________________
Which parent or caretaker were you closer to as a child/adolescent________________________________________
What do you identify as your ethnic background and/or nationality________________________________________
Please check if ___your and/or ___your parents immigrated to the U.S. If so, from where__________when______
Have you served in the military? ___Yes ___No If yes, what branch?___________________when___________
Commendations?_________________________Location(s)____________________Type of Discharge_________
Are you married? ___Yes ___No If yes, month and year____________have you ever been divorced ___Yes __No
Please list all work organizations, approximate dates of employment and reason for leaving (since your were an adult):
Workplace Dates of Employment Reason for Leaving
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
PREVIOUS THERAPY HISTORY
Please list all previous counseling, psychotherapy or treatment. Include outpatient and inpatient hospital stays. Begin with your earliest experience and work forward to present:
When (year) _______from_____to________ ___individual ___couple ___family ___group
Where (therapist/clinic/hospital)
Name____________________________________________City___________________________State_________
Reason for seeking help:_________________________________________________________________________
How was this experience helpful?__________________________________________________________________
Was medication prescribed during this? ___yes ___No If yes, medication______________Dosage:__________
Prescribed for what?_______________How long did you take this medication?_____Are you still taking it________
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PREVIOUS THERAPY HISTORY continued
When (year) _______from_____to________ ___individual ___couple ___family ___group
Where (therapist/clinic/hospital)
Name____________________________________________City___________________________State_________
Reason for seeking help:_________________________________________________________________________
How was this experience helpful?__________________________________________________________________
Was medication prescribed during this? ___yes ___No If yes, medication______________Dosage:__________
Prescribed for what?_______________How long did you take this medication?_____Are you still taking it________
When (year) _______from_____to________ ___individual ___couple ___family ___group
Where (therapist/clinic/hospital)
Name____________________________________________City___________________________State_________
Reason for seeking help:_________________________________________________________________________
How was this experience helpful?__________________________________________________________________
Was medication prescribed during this? ___yes ___No If yes, medication______________Dosage:__________
Prescribed for what?_______________How long did you take this medication?_____Are you still taking it________
When (year) _______from_____to________ ___individual ___couple ___family ___group
Where (therapist/clinic/hospital)
Name____________________________________________City___________________________State_________
Reason for seeking help:_________________________________________________________________________
How was this experience helpful?__________________________________________________________________
Was medication prescribed during this? ___yes ___No If yes, medication______________Dosage:__________
Prescribed for what?_______________How long did you take this medication?_____Are you still taking it________
To be completed by therapist:
Problem Summary:
1.___________________________________________________________________________________________
2.___________________________________________________________________________________________
3.___________________________________________________________________________________________
4.___________________________________________________________________________________________
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