PATIENT: __________________________ DATE: _

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	Decreased Energy	Delusions
Hopelessness	Guilt	Paranoia
Irritability	Medical Problems	Hyperactivity
Obsessions/Compulsions	Grief	Hallucinations
Panic Attacks	Anxiousness	Elevated Mood
Financial Problems	Eating Disorders	Sleep Problems
Problems with Friends	Legal Problems	Difficulty Concentrating
Problems at Work	Problems at School	Learning Problems
Problems with Activities Of Daily Living	Problems Controlling Temper	Marital Relationship Problems
Sexual Problems	Difficulty Thinking Clearly	Family Problems
Other:

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:

Substance Amount Frequency First Use Last Use

Previous treatment: Outpatient: Where and When _______________________________________________

Inpatient: Where and When_______________________________________________

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? ___

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: __________________________________________________________