Identification
Your Name (required)
Your Email (required)
Note: If you have been a client here before, please fill out only the information that has changed.
Date of Birth
Age
Home Address
City
State
Zip Code
Phone
Emergency Contact Information:
Name
Relationship
Phone 1
Phone 2
Marital Status:
—SingleMarriedDivorcedWidowedSeparatedPartnered
Religious Background:
—CatholicJewishProtestantOther
Race/Ethnic Background:
—African-AmericanCaucasianHispanicAsianNative-AmericanOther
Referral - Who gave you my name?
Address
May I have your permission to thank this person for the referral? —YesNo
Employment:
—Full-timePart-timeUnemployedRetiredStudent
Education:
—0-8 yearsHigh school graduateSome collegeCollege degreeSome technical schoolTechnical school graduateSome graduate schoolAdvanced or professional degree
Insurance:
Do you have insurance? —YesNo
If yes, would you like me to provide a statement that you can submit to your insurance company? —YesNo Note: I do not bill the insurance company directly, but I will provide you with a statement to send to your insurance company. Issues or Concerns:
Please describe briefly the issues or concerns for which you are presently seeking services
Previous Psychological or Psychiatric help:
Have you previously sought or received psychological or psychiatric help or counseling (including antidepressants, tranquillizers, Antabuse, pain medication or sleeping pills)? If yes, describe briefly
Is the present problem related to the earlier treatment? —YesNo
Have any other members of your family or household previously sought psychiatric help or counseling? If yes, describe briefly
Current living arrangement:
List the members of the household below. Please, write the Name, Age, Relationship and Occupation. 1. 2. 3. 4. 5.
List other members of your immediate family currently not living with you Please, write the Name, Age, Relationship and Occupation. 1. 2. 3.
Medical Screening Form: Physician Name
Physician Phone
Date of last physical exam
Are you currently receiving medical care? If yes, describe briefly
Current Medications:
List medications that you are currently using 1. 2. 3. 4. 5.
Have you ever had any bad reactions or allergies to any medications? If yes, please list
Indicate or list any major illnesses or medical conditions, surgeries or hospitalizations
1. head injury or paralysis Date Continuing Complications, if any
2. thyroid problems Date Continuing Complications, if any
3. asthma/shortness of breath Date Continuing Complications, if any
4. heart attack or stroke Date Continuing Complications, if any
5. high/low blood pressure Date Continuing Complications, if any
6. stomach or bowel disease Date Continuing Complications, if any
7. liver disease/jaundice Date Continuing Complications, if any
8. neurological disease Date Continuing Complications, if any
9. epilepsy Date Continuing Complications, if any
10. Other, please specify Date Continuing Complications, if any
Are you presently experiencing difficulty with any of the following symptoms?
headaches fainting spells/blackouts/dizziness heart pounding sugar/albumin in the urine anemia alcohol or drug problems frequent/painful urination change in sleep pattern chronic cough seizures or convulsions severe or prolonged nausea or vomiting memory loss/concentration change fatigue/change in energy levels change in appetite/recent weight gain or loss suicidal thoughts Other, please specify
Have you ever been tested for HIV? —YesNo
If so, when?
What was the result? —PositiveNegative
Note: This is a strictly confidential patient medical record. Redisclosure or transfer is expressly prohibited by law.
Tobacco use? —YesNo
Alcohol use? —YesNo
Recreational drug use? —YesNo
Age at first use
Please check any of the following that present problems for you.
—PastPresentBoth Depression/Sadness —PastPresentBoth Temper Outbursts —PastPresentBoth Energy Levels
—PastPresentBoth Loneliness —PastPresentBoth Legal Matters —PastPresentBoth Anxiety —PastPresentBoth Separation/Divorce —PastPresentBoth Violent Thoughts —PastPresentBoth Violent Actions —PastPresentBoth Education —PastPresentBoth Parenting —PastPresentBoth Drug Use —PastPresentBoth Alcohol Use —PastPresentBoth Chronic Pain —PastPresentBoth Long Term use of Medications —PastPresentBoth Assertiveness —PastPresentBoth Sexuality —PastPresentBoth Homework/Chores —PastPresentBoth Over Spending —PastPresentBoth Family Conflict —PastPresentBoth Racing thoughts —PastPresentBoth Self-Control —PastPresentBoth Stress —PastPresentBoth Headaches —PastPresentBoth Memory —PastPresentBoth Fear of Flying —PastPresentBoth Inferiority Feelings —PastPresentBoth Career Choices —PastPresentBoth Nightmares/Bad dreams —PastPresentBoth Oversleeping —PastPresentBoth Appetite —PastPresentBoth Fears/Phobias —PastPresentBoth Sleep Disturbances —PastPresentBoth Health Issues —PastPresentBoth Anger/Irritability —PastPresentBoth Suicidal Thoughts or Actions —PastPresentBoth Finances —PastPresentBoth Friendships —PastPresentBoth Unhappiness —PastPresentBoth Work —PastPresentBoth Exhaustion —PastPresentBoth Goal-Setting —PastPresentBoth Decision-Making —PastPresentBoth Concentration —PastPresentBoth Marriage/Love —PastPresentBoth Shyness —PastPresentBoth Procrastination —PastPresentBoth Relationships —PastPresentBoth Fidelity —PastPresentBoth Excessive Shopping —PastPresentBoth Gambling
Human Verification:
Please, write what you see in the image
LIMITS OF CONFIDENTIALITY
You have the right to confidentiality and privileged communication. No information about you or the services provided to you will be released without your permission.
I am, however, bound by my profession to breach confidentiality in the event that the following exceptional circumstances should present themselves.
1. If you indicate that you intend to hurt yourself or another, then I must notify potential helpers or victims if I believe there is a real danger.
2. If you report, or I suspect that you are a perpetrator or victim of child abuse or molestation, I am obligated to report this to the authorities if it is a current problem.
3. If a court of law issues a legitimate subpoena, then I am required to provide the information specifically described in the subpoena.
Every effort will be made to discuss with you a breach of confidentiality that is being considered and to resolve the issue to your satisfaction.
Please sign below to indicate that you have been informed of your rights regarding the release of confidential information.
Accept By accepting you are ensuring that you are a legal adult or the parent or guardian.