ĐĎॹá>ţ˙ fhţ˙˙˙e˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙˙ěĽÁ7 đżAQbjbjUU &t7|7|2M˙˙˙˙˙˙l€€€€€€€”   8Xlt”ž/śěěüüüˇ!ˇ!ˇ!///////$T0 t2śC/€ˇ!w!@ˇ!ˇ!ˇ!C/Ý%€€üü{X/Ý%Ý%Ý%ˇ!(€ü€ü/Ý%ˇ!/Ý%@ Ý%/€€/üŕ Đ×L;éÔÉ”Œ ß!Ş//n/0ž//*3‰$T*3/Ý%””€€€€ŮPerry Guthrie, Ph.D. Client History Patient/Client Name: ______________________________________ Date: ________________ Gender: ______ F ______ M Date of Birth: __________________ Age: ___________ Form completed by (if someone other than client): __________________________________ Address: ______________________________ City: ____________ State: ______ Zip: __________ Phone (home): _______________________ (work): _______________________ Ext. ____________ If you need any more space for any of the questions please use the back of the sheet. Primary reason(s) for seeking services: ______ Anger management ______ Anxiety ______Coping ______Depression ______ Eating disorder ______Fear/phobias ______Mental confusion ______Sexual concerns ______ Sleeping problems _____Addictive behaviors ______Alcohol/drugs ______ Other mental health concerns (specify): ______________________________________________ _______________________________________________________________________________ Family Information Living Living with you Relationship Name Age Yes No Yes No Mother _____________________________ _________ _____ _____ _____ _____ Father _____________________________ _________ _____ _____ _____ _____ Spouse _____________________________ _________ _____ _____ _____ _____ Children _____________________________ _________ _____ _____ _____ _____ _____________________________ _________ _____ _____ _____ _____ _____________________________ _________ _____ _____ _____ _____ Significant others (e.g., brothers, sisters, grandparents, step-relatives, half-relatives. Please specify relationship. Living Living with you Relationship Name Age Yes No Yes No __________ _____________________________ _________ _____ _____ _____ _____ __________ _____________________________ _________ _____ _____ _____ _____ __________ _____________________________ _________ _____ _____ _____ _____ __________ _____________________________ _________ _____ _____ _____ _____ __________ _____________________________ _________ _____ _____ _____ _____ __________ _____________________________ _________ _____ _____ _____ _____ Marital Status (more than one answer may apply) _____ Single _____Divorce in process _____Unmarried, living together Length of time: _____ Length of time: _____ _____Legally married _____Separated _____Divorced Length of time: _____ Length of time:_____ Length of time: _____ _____Widowed _____Annulment Length of time: _____ Length of time: _____ Total number of marriages: _______ Assessment of current relationship (if applicable): _____Good _____Fair _____Poor Parental Information _____Parents legally married _____Mother remarried: number of times: _____ _____Parents have ever been separated _____Father remarried: number of times:_____ _____Parents ever divorced Special circumstances (e.g., raised by person other than parents, information about spouse/children not living with you, etc.): __________________________________________________________________ Development Are there special, unusual, or traumatic circumstances that affected your development? Yes_____ No_____ If Yes, please describe: _________________________________________________________________ Has there been history of child abuse? Yes_____ No_____ If Yes, which type(s)? _____Sexual _____Physical _____Verbal If Yes, the abuse was as a: _____Victim _____Perpetrator Other childhood issues: _____Neglect _____Inadequate nutrition _____Other (please specify): ____________________________________________________________________________________ Comments re: childhood development: ____________________________________________________ Social Relationships Check how you generally get along with other people: (check all that apply) _____Affectionate _____Aggressive _____Avoidant _____Fight/argue often _____Follower _____Friendly _____Leader _____Outgoing _____Shy/withdrawn _____Submissive _____Other (specify): Sexual orientation: ______________ Comments: ____________________________________________ Sexual dysfunctions? _____Yes _____No If Yes, describe: _______________________________________________________________________ Any current or history of being a sexual perpetrator? _____Yes _____No If Yes, describe: _______________________________________________________________________ Cultural/Ethnic To which cultural or ethnic group, if any, do you belong? ______________________ Are you experiencing any problems due to cultural or ethnic issues? _____Yes _____No If Yes, describe: ______________________________________________________________________ Other cultural/ethnic information: ________________________________________________________ Spiritual/Religious How important to you are spiritual matters? _____Not _____Little _____Moderate _____Much Are you affiliated with a spiritual or religious group? _____Yes _____No If Yes, describe: __________________________________________________________ Were you raised within a spiritual or religious group? _____Yes _____No If Yes, describe: __________________________________________________________ Would you like your spiritual/religious beliefs incorporated into the counseling? _____Yes _____No If Yes, describe: __________________________________________________________ Legal Current Status Are you involved in any active cases (traffic, civil, criminal)? _____Yes _____No If Yes, please describe and indicate the court and hearing/trial date and charges: _ Are you presently on probation or parole? _____Yes _____No If Yes, please describe: Past History Traffic violations: _____Yes _____No DWI, DUI, etc.: _____Yes _____No Criminal involvement: _____Yes _____No Civil involvement: _____Yes _____No If you responded Yes to any of the above, please fill in the following information: Charges Date Where (city) Results ______________________________ ___________ __________________ _____________________ ______________________________ ___________ __________________ _____________________ ______________________________ ___________ __________________ _____________________ Education Fill in all that apply: Years of education:_____ Currently enrolled in school? _____Yes _____No _____High school grad/GED _____Vocational: Number of years:_____ Graduated: _____Yes _____No Major: _____College: Number of years:_____ Graduated: _____Yes _____No Major: _____Graduate: Number of years:_____ Graduated: _____Yes _____No Major: Other training: Special circumstances (e.g., learning disabilities, gifted): Employment Begin with most recent job, list job history: Employer Dates Title Reasons left job How often miss work? _____________________ ____________ ___________ _________________ _____________________ ____________ ___________ _________________ _____________________ ____________ ___________ _________________ Currently: _____FT _____PT _____Temp _____Laid-off _____Disabled _____Retired _____Social Security _____Student _____Other (describe) Military Military experience? _____Yes _____No Combat experience? _____Yes _____No Where: Branch: _______________________________ Discharge date: Date drafted: ___________________________ Type of discharge: Date enlisted: ___________________________ Rank at discharge: Leisure/Recreational Describe special areas of interest or hobbies (e.g., art, books, crafts, physical fitness, sports, outdoor activities, church activities, walking, exercising, diet/health, hunting, fishing, bowling, traveling, etc.) Activity How often now? How often in the past? _______________________________ ____________________ ____________________ _______________________________ ____________________ ____________________ _______________________________ ____________________ ____________________ _______________________________ ____________________ ____________________ Medical/Physical Health ____ AIDS ____ Dizziness ____Nose bleeds ____ Alcoholism ____ Drug abuse ____ Pneumonia ____ Abdominal pain ____ Epilepsy ____ Rheumatic Fever ____ Abortion ____ Ear infections ____ Sexually transmitted diseases ____ Allergies ____ Eating problems ____ Sleeping disorders ____ Anemia ____ Fainting ____ Sore throat ____ Appendicitis ____ Fatigue ____ Scarlet fever ____ Arthritis ____ Frequent urination ____ Sinusitis ____ Asthma ____ Headaches ____ Smallpox ____ Bronchitis ____ Hearing problems ____ Stroke ____ Bed wetting ____ Hepatitis ____ Sexual problems ____ Cancer ____ High blood pressure ____ Tonsillitis ____ Chest pain ____ Kidney problems ____ Tuberculosis ____ Chronic pain ____ Measles ____ Toothache ____ Colds/Coughs ____ Mononucleosis ____ Thyroid problems ____ Constipation ____ Mumps ____ Vision problems ____ Chicken Pox ____ Menstrual pain ____ Vomiting ____ Dental problems ____ Miscarriages ____ Whooping cough ____ Diabetes ____ Neurological disorders ____ Other (describe): __________________ ____ Diarrhea ____ Nausea __________________ List any current health concerns: List any recent health or physical changes: _ Nutrition Meal How often Typical foods eaten Typical amount eaten f (times per week) Breakfast ____ / week ___________________ ____No ____Low ____ Med ____ High Lunch ____ / week ___________________ ____No ____Low ____ Med ____ High Dinner ____ / week ___________________ ____No ____Low ____ Med ____ High Snacks ____ / week ___________________ ____No ____Low ____ Med ____ High Comments: Current prescribed medications Dose Dates Purpose Side Effects ________________________ __________ _____________ _______________ _______________ ________________________ __________ _____________ _______________ _______________ ________________________ __________ _____________ _______________ _______________ ________________________ __________ _____________ _______________ _______________ Current over-the-counter meds Dose Dates Purpose Side Effects ________________________ __________ _____________ _______________ _______________ ________________________ __________ _____________ _______________ _______________ ________________________ __________ _____________ _______________ _______________ ________________________ __________ _____________ _______________ _______________ Are you allergic to any medications or drugs? _____Yes _____No If Yes, describe: Date Reason Results f Last physical exam ____________ ____________________ _______________________ Last doctor’s visit ____________ ____________________ _______________________ Last dental exam ____________ ____________________ _______________________ Most recent surgery ____________ ____________________ _______________________ Other surgery ____________ ____________________ _______________________ Upcoming surgery ____________ ____________________ _______________________ Family history of medical problems: Please check if there have been recent changes in the following: ____Sleep patterns ____Eating patterns ____Behavior ____Energy level ____Physical activity level ____General disposition ____Weight ____Nervousness/tension Describe changes in areas in which you checked above: _ Chemical Use History Method of Use & Frequency of Age of Age of Used in the Used in the Amount Use 1st Use Last Use last 48 hrs? last 30 days? Y N Y N Alcohol ______________ __________ _______ ______ ___ ___ ___ ___ Barbiturates ______________ __________ _______ ______ ___ ___ ___ ___ Valium/Librium ______________ __________ _______ ______ ___ ___ ___ ___ Cocaine/Crack ______________ __________ _______ ______ ___ ___ ___ ___ Heroin/Opiates ______________ __________ _______ ______ ___ ___ ___ ___ Marijuana ______________ __________ _______ ______ ___ ___ ___ ___ PCP/LSD/ Mescaline ______________ __________ _______ ______ ___ ___ ___ ___ Inhalants ______________ __________ _______ ______ ___ ___ ___ ___ Caffeine ______________ __________ _______ ______ ___ ___ ___ ___ Nicotine ______________ __________ _______ ______ ___ ___ ___ ___ Over the counter ______________ __________ _______ ______ ___ ___ ___ ___ Prescription drugs ______________ __________ _______ ______ ___ ___ ___ ___ Other drugs ______________ __________ _______ ______ ___ ___ ___ ___ Substance of preference 1. _________________________________ 3. _________________________________ 2. _________________________________ 4. _________________________________ Substance Abuse Questions Describe when and where you typically use substances: _ Describe any changes in your use patterns: _ Describe how your use affected your family or friends (include their perceptions of your use): _ Reason(s) for use: ____Addicted ____Build confidence ____Escape ____Self-medication ____Socialization ____Taste ____Other (specify): __________________________ How do you believe your substance use affects your life? Who or what has helped you in stopping or limiting your use? Does/has someone in your family present/past have/had a problem with drugs or alcohol? ____Yes ____No If Yes, describe: Have you had withdrawal symptoms when trying to stop using drugs or alcohol? ____Yes ____No If Yes, describe: Have you had adverse reactions or overdose to drugs or alcohol? If Yes, describe: _ Does your body temperature change when you drink? ____Yes ____No If Yes, describe: Have drugs or alcohol created a problem for your job? ____Yes ____No If Yes, describe: Counseling/Prior Treatment History Information about client (past and present): Your reaction Yes No When Where to overall experience Counseling/Psychiatric Treatment ____ ____ ________ ____________ __________________________ Suicidal thoughts/ Attempts ____ ____ ________ ____________ __________________________ Drug/alcohol treatment ____ ____ ________ ____________ __________________________ Hospitalizations ____ ____ ________ ____________ __________________________ Involvement with self-help groups (e.g., AA, Al-Anon NA, Overeaters Anonymous)____ ____ ________ ____________ __________________________ Information about family/significant others (past and present): Your reaction Yes No When Where to overall experience Counseling/Psychiatric Treatment ____ ____ ________ ____________ __________________________ Suicidal thoughts/ Attempts ____ ____ ________ ____________ __________________________ Drug/alcohol treatment ____ ____ ________ ____________ __________________________ Hospitalizations ____ ____ ________ ____________ __________________________ Involvement with self-help groups (e.g., AA, Al-Anon NA, Overeaters Anonymous) ____ ____ ________ ____________ __________________________ Please check behaviors and symptoms that occur to you more often than you would like them to take place: ____ Aggression ____ Elevated mood ____ Phobias/fears ____ Alcohol dependence ____ Fatigue ____ Recurring thoughts ____ Anger ____ Gambling ____ Sexual addiction ____ Antisocial behavior ____ Hallucinations ____ Sexual difficulties ____ Anxiety ____ Heart palpitations ____ Sick often ____ Avoiding people ____ High blood pressure ____ Sleeping problems ____ Chest pain ____ Hopelessness ____ Speech problems ____ Cyber addiction ____ Impulsivity ____ Suicidal thoughts ____ Depression ____ Irritability ____ Thoughts disorganized ____ Disorientation ____ Judgment errors ____ Trembling ____ Distractibility ____ Loneliness ____ Withdrawing ____ Dizziness ____ Memory impairment ____ Worrying ____ Drug dependence ____ Mood shifts ____ Other (specify): ____ Eating disorder ____ Panic attacks _________________________________ Briefly discuss how the above symptoms impair your ability to function effectively: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Any additional information that would assist us in understanding your concerns or problems: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ What are your goals for therapy? _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Do you feel suicidal at this time? _____Yes _____No If Yes, explain: _____________________________________________________________________________________ _____________________________________________________________________________________ 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