PRESENTING PROBLEM(S): (Please describe your
reasons for seeking counseling at this time.)
Was there an event that made these issues or problems
surface? If yes, please describe:
PRESENTING SYMPTOMS: (check all that apply)
Depressed Mood |
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Decreased Energy |
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Delusions |
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Hopelessness |
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Guilt |
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Paranoia |
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Irritability |
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Medical Problems |
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Hyperactivity |
|
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Obsessions/Compulsions |
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Grief |
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Hallucinations |
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Panic Attacks |
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Anxiousness |
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Elevated Mood |
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Financial Problems |
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Eating Disorders |
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Sleep Problems |
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Problems with Friends |
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Legal Problems |
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Difficulty Concentrating |
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Problems at Work |
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Problems at School |
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Learning Problems |
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Problems with Activities Of Daily Living |
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Problems Controlling Temper |
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Marital Relationship Problems |
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Sexual Problems |
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Difficulty Thinking Clearly |
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Family Problems |
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Other: |
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FAMILY HISTORY: Describe any medical or psychiatric
conditions of your parents or siblings:
PSYCHIATRIC HISTORY:
Include all current/prior inpatient and outpatient treatment, including
dates, when you were in treatment; name of therapist or doctor; names of all
medication(s), dosage(s) and date last taken:
Is another behavioral health specialist currently treating
you? Yes___ No___ If yes, who are you
seeing?
MEDICAL HISTORY: Include current and previous
medical problems, current and previous providers, dates of treatment/surgeries,
all medications you are taking, including dosage and any over-the-counter
medication you are currently taking).
Are you in agreement with your current medication plan? Yes___No___ If not, please describe_________________________________
______________________________________________________________________________________________________________
ALLERGIES TO
FOOD: Yes____ No_____ Medication Yes ____ No ____ If yes, please
describe _______
_________________________________________________________________________________________________________
MEDICATION: Have you ever had an adverse reaction/side effect (s) to any
medication(s): YES_____ NO______
(If yes, please
list)___________________________________________________________________________________
SUBSTANCE ABUSE: HAVE YOU EVER ABUSED DRUGS OR
ALCOHOL? YES_____ NO ______
If yes, complete the following:
Cigarette use: YES___ NO____ Number
per day: ______ Caffeine Use: YES___ NO____ Amount__________
Patient:
______________________________________ Date:_______________________
PSYCHOSOCIAL
HISTORY:
Legal Issues
________________________________________________________________________________
Spiritual/Religious
Affiliation ___________________________________________________________________
Educational
History:
__________________________________________________________________________
Employment
History: __________________________________________________________________________
Cultural
Influence/Concerns:
____________________________________________________________________
Community
Resources:
________________________________________________________________________
Social Supports:
______________________________________________________________________________
Are there
supports you need to develop or expand?
Yes____ No____ If yes, please describe: ________________
___________________________________________________________________________________________
My Strengths:
My Weaknesses: _____
What behaviors do
you exhibit when
angry?_____________________________________________________________
What calms you
down? _____________________________________________________________________________
What are your triggers? ___
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Developmental
History for Children and Adolescent Patients ONLY
Do you have any
concerns about your child’s prenatal development? Yes____ No____ If yes, please
describe_________
________________________________________________________________________________________________
Do you have any
concerns about your child’s birth or early infancy? Yes____ No____ If yes,
please describe_________
_________________________________________________________________________________________________
Do you have any
concerns about your child’s development (walking, talking, toileting?)? Yes____
No____ If yes, please describe__________________________________________________________________________________________
Does your child
have any physical problems? Yes____ No
____
Does your child
have any psychological problems? Yes____ No ____
Does your child
have any social problems? Yes____ No ____
Does your child
have any intellectual problems? Yes____ No ____
Does your child
have any academic problems? Yes____ No ____
Are there other
areas that concern you? Yes____ No ____
Please describe
any problems identified above:
__________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
What behaviors do
you exhibit when angry?_____________________________________________________________
What calms you
down?
_____________________________________________________________________________
What are your
triggers?
_____________________________________________________________________________