First Name:                                                                           Age:             

Can you describe for me what are your reasons for seeking treatment at this time? and what you hope to change?

Have you seen a mental health or substance abuse professional (psychiatrist, psychologist, or social worker) in the past? If yes, explain.

Have you ever taken medications for a mental health, emotional problem, or substance abuse problem?  If yes, explain:

_____________________________________________________________________________________

Have you attended any self-help groups?  If so, explain:

Family Information

Spouse’s name	Spouse’s Date of Birth	Spouse’s Occupation

Children’s Name(s), age(s), sex.  Specify if child lives at home.  Previous marriage(s) and children.

_____________________________________________________________________________________
List significant extended family members Names & approx. age.  (Parent, brothers and sisters, etc.)

Explain any family history of physical illness or significant hospitalizations.

_____________________________________________________________________________________
Explain any family history of mental or emotional illnesses, psychiatric hospitalization, history of suicide.

_____________________________________________________________________________________
Any family history of substance abuse?  Who was that?  What substance(s) was abused?

_____________________________________________________________________________________
Please describe any spiritual/religious/cultural affiliations.

_____________________________________________________________________________________
Are social supports adequate at present?  (Family, friends, co-workers)  Name your two closest supportive friends
or family members

_____________________________________________________________________________________

Occupational/Educational History

Current employer and your job title

____________________________________________________________________________________

General satisfaction with your job

____________________________________________________________________________________

List past jobs and any comments:

____________________________________________________________________________________

1

Are you satisfied with your overall financial status?  If not, explain.

____________________________________________________________________________________
Highest grade completed:

____________________________________________________________________________________
Describe your school performance:

____________________________________________________________________________________
Do you have any future plans for education?  If yes, describe.

____________________________________________________________________________________
Leisure Activities

____________________________________________________________________________________
List some of your hobbies, activities, and talents.

____________________________________________________________________________________

With whom do you spend most of your free time?

____________________________________________________________________________________

Medical History
____________________________________________________________________________________

Name and address of your primary care physician

____________________________________________________________________________________

Height:     ft      in.                               Weight:          lbs.

____________________________________________________________________________________
When was your last physical exam?

____________________________________________________________________________________
Do you have any allergies?  If yes, explain.

____________________________________________________________________________________
List all prescribed medications you are taking.  Include dosage and frequency.

____________________________________________________________________________________

List all over-the-counter (including vitamins, minerals, diet pills, supplements, herbs, and other “natural” remedies) you are taking.

____________________________________________________________________________________

Have you ever had a problem with overuse of prescribed medications?  If yes, explain.

____________________________________________________________________________________
Describe any surgeries, serious accidents, or hospital admissions.

_____________________________________________________________________________________

Indicate whether you have had any of the following illnesses/symptoms.

	Now		Ever			Now		Ever		
	Yes	No	Yes	No		Yes	No	Yes	No	
Anemia					High blood pressure					
Arthritis					Immune problems					
Asthma					Kidney disease					
Cancer					Paralysis					

2

	Now		Ever			Now		Ever		
	Yes	No	Yes	No		Yes	No	Yes	No	
Diabetes					Prostate problems					
Earaches, infections					Seizures, epilepsy					
Emphysema					STDs					
Fainting/dizziness					Sleep problems					
Excessive fatigue					Stroke					
Headaches					Thyroid disease					
Head injury					Ulcers (GI)					
Heart problems					Urinary infections					
Hepatitis					Vision/hearing problems					
Other:					Other:					
Do you have physical pain?  Yes_____No_____
If yes, rate the intensity of the pain:  1(mild) to 5 (severe): ____________.

If yes, where is the pain located: _________________________________________________. If yes, how does it impact your functioning?

_____________________________________________________________________________________

Do you drink coffee, tea, cola, or consume other food, beverages, or medicines with caffeine? If so, please describe how much per day?

_____________________________________________________________________________________
Please provide information on your use of non-medical drugs.

Substance	Used within 48 hrs.?	How often used?	Year first used?	When last used?	
Cigarettes/tobacco								
Alcohol								
Sleeping pills								
Marijuana								
Inhalants								
Cocaine/crack								
Heroin								
Other:								
Military History								
Branch		Rank		Time in service	Active combat	
								
Legal History
_____________________________________________________________________________________
Do you have any pending or prior legal problems?  If yes, explain.

_____________________________________________________________________________________

Other:
Is there anything else you think we ought to know about you or you would like to tell us?

_____________________________________________________________________________________

Patient Signature:_______________________________________Date:_________________________

For therapist use only:

If it has been over a year since the patient’s last physical, did you suggest that he/she have a physical? Yes_____No_____ Did the patient agree to this? Yes_____ No_____

Therapist/MD signature:_____________________________________Date:_______________________

3

ADULT SYMPTOM CHECKLIST

NAME:____________________________ AGE:______________ DATE:______________________
__________________________________________________________________________________________

Please circle the symptoms that apply to you now in the past few weeks:

Never  Rarely	Sometimes		Always	
Depression	0	1	2	3	4	5	
Crying spells	0	1	2	3	4	5	
Hopelessness	0	1	2	3	4	5	
Worthlessness	0	1	2	3	4	5	
Sleep disturbance	0	1	2	3	4	5	
Trouble falling asleep	0	1	2	3	4	5	
Interrupted sleep	0	1	2	3	4	5	
Early morning wakening	0	1	2	3	4	5	
Oversleeping	0	1	2	3	4	5	
Loss of appetite	0	1	2	3	4	5	
Overeating	0	1	2	3	4	5	
Weight loss or gain	0	1	2	3	4	5	
If so, how much in the last 3-6 months:						
Gained:_____Lost:______							
Lack of interest in usual things	0	1	2	3	4	5	
Suicidal thoughts, present	0	1	2	3	4	5	
Suicidal thoughts, past	Yes_____No_____	
Suicide attempt, gesture	Yes_____No_____	
Homicidal thoughts	0	1	2	3	4	5	
Anxiety, nervousness	0	1	2	3	4	5	
Irritability, edginess	0	1	2	3	4	5	
Mood swings	0	1	2	3	4	5	
Racing thoughts	0	1	2	3	4	5	
Hard to concentrate/	0	1	2	3	4	5	
stay focused on task							
Fatigue/tiredness	0	1	2	3	4	5	
Bursts of energy	0	1	2	3	4	5	
Worry	0	1	2	3	4	5	
Fears of ordinary things	0	1	2	3	4	5	
(for example, crowds, germs, doctors, flying, closed spaces)

Yelling/screaming	0	1	2	3	4	5	

On the go, hard to relax	0	1	2	3	4	5	
Periodic overspending	0	1	2	3	4	5	
Gambling problem	0	1	2	3	4	5	
Alcohol problem	0	1	2	3	4	5	
(in the last year)							
Drug problem	0	1	2	3	4	5	
(in the last year)							
Blackouts, shakes, tremors	0	1	2	3	4	5	
Anxiety/panic attacks	0	1	2	3	4	5	
Heart beating fast	0	1	2	3	4	5	
Chest pains/tightness	0	1	2	3	4	5	
Lightheadedness	0	1	2	3	4	5	
Stomach upset	0	1	2	3	4	5	
Sexual difficulties	0	1	2	3	4	5	
Relationship problems	0	1	2	3	4	5	
Work problems	0	1	2	3	4	5	
Eating disorder	0	1	2	3	4	5	
Suspiciousness/paranoia	0	1	2	3	4	5	
Feeling controlled	0	1	2	3	4	5	
Hitting/domestic violence	0	1	2	3	4	5	
Hearing voices	0	1	2	3	4	5	
(that others don’t)							
Seeing things	0	1	2	3	4	5	
(that others don’t)							
Need for cleanliness	0	1	2	3	4	5	
Need for organization	0	1	2	3	4	5	
Counting behavior/thoughts	0	1	2	3	4	5	
Rituals that you must do/	0	1	2	3	4	5	
need to check and recheck							
Unexplained physical symptoms 0	1	2	3	4	5	
Trauma, other abuse	0	1	2	3	4	5