Client Personal DataDemographics:Patient First Name(Required) Last Name(Required) Date Month Day Year Office ID# Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code SS# Date of Birth(Required) Month Day Year Phone(Required)Email(Required) Referred by Military Rank Race Gender Marital Status Spouse Name Employer Position Work PhonePrimary Care Physician Psychiatrist Had Previous Therapy Date of Last Therapy Month Day Year InsuranceInsurance Carrier Policy # Group # Total Sessions Authorized General NotesDescribe the current presenting concerns(Required)Emotional / PsychiatricPrior OUTPATIENT psychotherapy? Yes No If Yes, on how many occasions? Longest treatment by __________________ for _____ sessions from _________ to _________.Please fill in the blanks below, separate by a comma Prior Provider Name Provider Address Diagnosis Intervention / Modality Beneficial? Has any family member had outpatient psychotherapy? Yes No If yes, who/why Prior INPATIENT treatment for a psychiatric, emotional, or substance use disorder? Yes No If Yes, on how many occasions? Longest treatment at __________________________________ (location) from __________ to __________.Please fill in the blanks below, separate by a comma Has any family member had inpatient treatment for a psychiatric, emotional, or substance use disorder? Yes No If yes, who/why Prior or current psychotropic medication usage? Yes No Medication Dosage Frequency Start/End Dates Physician Side effects Beneficial? Has any family member used psychotropic medications? Yes No If yes, who/why Family HistoryFamily of OriginMother present in childhood All Part None Father present in childhood All Part None Stepmother present in childhood All Part None Stepfather present in childhood All Part None Brother(s) present in childhood All Part None Other(s) present in childhood All Part None Sister(s) present in childhood All Part None Father's Full Name Father's Occupation Father's Education Father's Health Please describeMother's Full Name Mother's Occupation Mother's Health Please describeMother's Education Parents current marital status Please fill out all that applyMarried to each other Yes No Divorced for ________ years Separated for _______ years Mother remarried _______ times Mother deceased for ______ years at age ______ Mother involved with someone Yes No Father involved with someone Yes No Mother deceased for ______ years at age ______ Father deceased for ______ years at age ______ Describe childhood family experience: Outstanding home environment Normal home environment Chaotic home environment Witnessed physical/verbal/sexual abuse Experienced physical/verbal/sex abuse Special circumstances in childhoodAge of Emancipation from Home Circumstances Immediate FamilyMarital Status: Cohabitating Divorced Married Separated Single Widowed Intimate Relationship: Cohabitating Never been in a serious relationship Not currently in relationship Relationship Satisfaction: Very satisfied with relationship Satisfied with relationship Somewhat satisfied with relationship Dissatisfied with relationship Very dissatisfied with relationship List all persons currently living in household. Include Name, Age, Sex, RelationshipList Biological/Adopted children NOT living in household. Include Name, Age, Sex, RelationshipFrequency of Visitation of Above Describe any past or current significant issues in intimate relationshipsDescribe any past or current significant issues in other immediate family relationshipsMedicalDescribe current physical health: Good Fair Poor Details of Health Condition:List Name of Primary Care Physician Primary Care Physician Phone: List Name of Psychiatrist (if any): Psychiatrist Phone: 1. List Any Non-Psychiatric Medications Currently Being Taken: List Name___, Reason___, Dosage____ 2. List Any Non-Psychiatric Medications Currently Being Taken: List Name___, Reason___, Dosage____ 3. List Any Non-Psychiatric Medications Currently Being Taken: List Name___, Reason___, Dosage____ List Any Known Allergies: Is there a history of any of the following in the family: Tuberculosis Drug Abuse Thyroid Problems Stroke Alcoholism Birth Defects Diabetes Cancer Heart Disease Alzheimer’s Disease Emotional Problems Behavior Problems Intellectual Disability High Blood Press Dementia Other Chronic or Serious Health Problems in Family Members: Describe any serious hospitalizations or accidents: List any abnormal lab test results: Substance UseFamily Alcohol/Drug Abuse History: Father Mother Grandparent(s) Siblings Step-Parent/Live-in Uncle(s)/Aunt(s) Spouse/Significant Other Children Other: Other Family Alcohol/Drug Abuse History Substance Use Status: No history of abuse Active abuse Early full remission Early partial remission Sustained full permission Sustained partial remission Patient Treatment History: Outpatient at age Inpatient at age 12 step program age Stopped on own age Other: Please specify age to any items applicable in field below.Specify Age(s) for patient treatment history and specify Other if selected.Substances Used: Alcohol Amphetamines/Speed Barbiturates/Owners Cocaine Crack Cocaine Hallucinogens Inhalants (e.g. glue, gas) Marijuana or Hashish Opioids PCP Prescription Other Specify Other Substances Used: Please list Substance used____, First Use Age____, Last Use Age____, Current Use____, Frequency____, Amount____Consequences of Substance Abuse: Hangovers Seizures Blackouts Accidental Overdose Arrests Binges Withdrawal Symptoms Medical Conditions Increase in Tolerance Loss of Control with Amount Job Loss Sleep Disturbance Assaults Suicide Attempts Suicidal Impulses/Thoughts Relationship Conflicts Developmental HistoryProblems During Mother’s Pregnancy: None High Blood Pressure Kidney Infection German Measles Emotional Stress Bleeding Alcohol Use Drug Use Cigarette Use Other: Specify Other Problems During Mother’s Pregnancy: Birth: Normal Delivery Difficult Delivery Cesarean Delivery Complications: Birth Weight: Please list any complications and birth weight. Infancy Problems: None Feeding Problems Sleep Problems Toilet Training Problems Childhood Health: Chickenpox at age _____ German Measles at age _____ Red Measles at age _____ Whooping Cough at age _____ Autism Asthma Lead Poisoning at age _____ Mumps at age _____ Diphtheria at age _____ Scarlet Fever at age _____ Mental Retardation age _____ Tuberculosis at age _____ Poliomyelitis at age _____ Rheumatic Fever at age _____ Pneumonia at age _____ Ear Infections Allergies: ______ Significant Injuries: __________ Chronic Health Problems: _______ List age(s) and any other details such as allergies, significant injuries and health problems in the field below.List age(s) and any other details such as allergies, significant injuries and health problemsDelayed Developmental Milestones (not occurring at expected age): Sitting Rolling Over Standing Walking Controlling Bladder Riding Bicycle Dressing Self Engaging Peers Controlling Bowels Riding Tricycle Feeding Self Tolerating Separating Playing Cooperatively Sleeping Alone Speaking Words Speaking Sentences Other List Other Delayed Developmental Milestones (not occurring at expected age): Emotional/Behavior Problems: None Drug Use Alcohol Abuse Chronic Lying Stealing Violent Temper Fire-Setting Hyperactive Animal Cruelty Assaults Others Disobedient Repeat Other’s Words Not Trustworthy Hostile/Angry Mood Indecisive Immature Bizarre Behavior Self-injurious Threats Frequently Tearful Lack of Attachment Extreme Worrier Impulsive Poor Concentration Breaks Things in Anger Distrustful Self-injurious Acts Easily Distracted Often Sad Frequent Daydreams Other List Other Emotional/Behavior Problems: Social Interaction: Normal Social Interaction Isolates Self Very Shy Associates w/Acting-Out Peers Inappropriate Sex Play Dominates Others Alienates Self Other List Other Social Interaction: Intellectual/Academic Functioning: Normal Intelligence High Intelligence Learning Problems Authority Conflicts Attention Problems Underachieving Mild Retardation Moderate Retardation Severe Retardation Current or Highest Education Level Describe any other development problems or issues:Socio-Economic HistoryLiving Adequate: Housing Adequate Homeless Housing Overcrowded Dependent on Others for Housing Housing Dangerous/Deteriorating Living Companions Dysfunctional Military: Never in Military Served in Military – no incident Service in Military – with incident Military - Provide details: Social Support System: Supportive Network Few Friends Substance-use-based Friends No Friends Distant from Family of Origin Employment: Employed and Satisfied Employed but Dissatisfied Unemployed Coworker Conflicts Supervisor Conflicts Unstable Work History Disabled_______ Specify Disability: Legal History: No Legal Problems Now on Parole/Probation Arrest(s) Not Substance-related Court Ordered this Treatment Jail/Prison for ______ total time List Jail / Prison Total Time: Describe last legal difficulty: Sexual History: Age First Sex Experience: Age First Pregnancy/Fatherhood: History of Promiscuity Age_____ - ____ History of Unsafe Sex Age _____ - ____ Additional Information: ____________ Cultural/Spiritual/Recreational History:Cultural Identity (e.g. ethnicity, religion) Describe any cultural issues that contribute to current problem and/or should be taken into account during treatment planning:Cultural/Spiritual/Recreational Activity: Currently Active in Community / Recreational Activities Formerly Active in Community / Recreational Activities Currently Engaged in Hobbies Currently Participate in Spiritual Activities Additional information Relating to Cultural/Spiritual/Recreational History: Sources of DataSources fo Data Patient self-report for all A variety of sources (check appropriate sources below) For Presenting Problems/Symptoms - Please specify if Patient Self-report, Patient's Parent / Guardian or Other For Family History - Please specify if Patient Self-report, Patient's Parent / Guardian or Other For Developmental History - Please specify if Patient Self-report, Patient's Parent / Guardian or Other For Emotional/Psychiatric History - Please specify if Patient Self-report, Patient's Parent / Guardian or Other For Medical/Substance Use History - Please specify if Patient Self-report, Patient's Parent / Guardian or Other For Socioeconomic History - Please specify if Patient Self-report, Patient's Parent / Guardian or Other
