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New Cover Page
Home
Psychology Today profile
Intake Forms
Contact
About
Client Information
Consent to Treatment
Psyc Emp Serv Policies and Practices
HIPPA - Notice of Privacy Practices
Credit Card Acknowledgement form
This is a strictly confidential patient medical record. Re-disclosure or transfer is expressly prohibited by law.
Adult Client Information Form2:
NOTE: If you were a patient here before, please fill in only the information that has changed.
Today's Date
*
MM
DD
YYYY
A. Identification
Name:
*
First Name
Last Name
B. Treatment history
Have you ever received inpatient of outpatient psychological, psychiatric, drug / alcohol treatment, medications, or counseling services before?
*
Yes
No
Please enter in Dates of treatment, diagnosis', type of treatment:
Please indicate where / from whom treatment was received:
What were the results?
Has any relative had inpatient treatment for a psychiatric, emotional, or substance use disorder?
Yes
No
If yes, please describe. Please include persons name(s), relationship, diagnoses, treatment, provider, dates, and results.
List all medications, herbs, or supplements you are taking for mental, emotional, or psychiatric conditions:
C. Relationships in your family of origin
Please describe the following:
1. Your parents' or stepparents' relationship(s) with each other:
2. Your relationship with each parent and with any other adults present with you when you were growing up:
3. Your parents' physical health problems, drug or alcohol use, and mental or emotional difficulties:
4. Your relationship with your brothers and sisters (or step siblings), in the past and present:
D. Abuse History
NOTE: Please be aware as you answer these questions that if I suspect there is a risk of abuse, I have to report it. You may leave this section blank for discussion later.
Abuse history:
I was not abused in any way
I may have been abused in some way
I was abused - please explain in next field
Please indicate the following: for kind of abuse, use these letters: P = physical, such as beatings; S = sexual, such as touching/molesting, fondling, or intercourse; N = neglect, such as failure to feed, shelter, or protect; E = emotional, such as humiliation, etc.
E. Chemical use
1a. How many caffeinated drinks (coffee, tea, colas, energy drinks, etc.) do you use each day?
1b. How often each week do you use medications (prescription or over-the-counter) or chemicals to be more alert or sharper?
2a. How much tobacco to you smoke or chew each week?
2b. Do you use vapor or e-cigarettes?
Yes
No
If yes - how many per week?
3. How many drinks of beer, wine, or hard liquor do you consume in a typical week?
4. Have you ever felt the need to cut down on your drinking?
Yes
No
5. Have you ever felt annoyed by criticism of your drinking?
Yes
No
6. Have you ever felt guilty about your drinking?
Yes
No
7. Have you ever taken a morning "eye opener"?
Yes
No
8. Did you ever drink to unconsciousness, or run out of money because of drinking?
Yes
No
9. Have you ever used inhalants ("huffing"), such as glue, gasoline, or paint thinner?
Yes
No
If yes, which substances and when?
10. Which drugs (not medications prescribed to you) have you used in the past 10 years?
11. Do you think you have a drug or alcohol problem?
Yes
No
F. Legal History
1. Are you presently being sued, suing anyone, or thinking of suing anyone?
Yes
No
If yes, please explain:
2. Is your reason for coming to see me related to an accident or injury?
Yes
No
If yes, please explain:
3. Are you required by a court or probation / parole officer to have this appointment?
Yes
No
If yes, please explain:
4a. List all contacts with the police, courts, and jails / priosons you have had. Include all open charges and pending ones. Indicate the "Jurisdiction" by using the following letters: F = federal, S = state, CO = county, Ci = City.
4b. Indicate (if applicable) and "Sentence" you have have received. Include time and type of sentence. Use the following letters: CD = Charges Dropped; AR = Accelerated Release or Alternative Resolution; CS = Community Service; F = Fine; I = Incarceration (jail or prison); PR = PRobation; P = Parole; R = Resolution; O = Other
5. Your current attorney's name and telephone number:
6. Have you ever declared bankruptcy?
Yes
No
If yes, when?
7. Have you ever had any other legal involvements?
Yes
No
If yes, please explain:
G. Other
Is there anything else that is important for you to tell me as your therapist to know about, and that you have not written about on any of these forms?
Yes
No
If yes, please tell me about it here:
