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* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
INTAKE INFORMATION I’d like to get some background information from you ahead of time so that you don’t have to spend your entire first session explaining it all to me. While I may need to ask you some additional questions to clarify, your completion of this form should help me understand your situation more quickly. I appreciate you taking the time to provide this information. Thank you. Name: _________________________________________ Date: ______________ Please check all of the behaviors and symptoms that are problems for you: Anxiety Issues Attention Issues Frequent worry Distractibility Panic attacks Hyperactivity Social discomfort Impulsivity Fear away from home Easily confused Phobias____________ Poor memory Obsessive thoughts Racing thoughts Compulsive behavior______ Flashbacks Anger Issues Nightmares Physical aggression Suspicion/paranoia Irritability/anger Homicidal thoughts Mood Issues Peer conflict Crying spells Property destruction Sadness/depression Fatigue General Issues Lack of motivation Alcohol/drug use Hopelessness Computer addiction Guilt Eating problems Inability to enjoy things Gambling problems Low self worth Problems with pornography Shame Parenting problems Wide mood swings Relationship problems Withdrawal from people Sexual problems Self-harm behaviors Social isolation Thoughts of death/suicide Sleep problems Work/school problems Have you ever attempted to commit suicide? No Have you ever attempted to assault or kill someone? Child/Adolescent Only Curfew violation Defiance Fire setting Lying Running away Sibling conflict Stealing Toileting problems Other Issues Hearing voices Visual hallucinations __________________ __________________ Yes, when? ______________________ No Have you ever been physically hurt/threatened by someone? Yes, when? _________________ No Yes, when? ___________ Please check if you have experienced any of the following types of trauma or loss: Emotional abuse Sexual abuse Physical abuse Neglect Parent substance abuse Parent illness (during your childhood) Teen pregnancy Placed a child for adoption Lived in a foster home Multiple family moves Violence in the home Homelessness Crime victim Were there any problems with your birth (i.e., fetal distress, emergency c-section, etc)? No Yes, what? ________________________________________________________ Did you have any extreme sensitivity to noise, texture, or taste as a young child? No Yes, what? ________________________________________________________ 1 Name: ______________________________________________ FAMILY INFORMATION Parents legally married or living together Parents temporarily separated Parents divorced or permanently separated Parents’ ages: Mother _____ Mother remarried: Number of times ________ Father remarried: Number of times ________ Parent deceased: Which one? ____________ Father _____ Stepmother _____ Stepfather _____ Your place in birth order (oldest, youngest, etc): _______________ Brothers and their ages:_______________________________________________________ Sisters and their ages: ________________________________________________________ Marital Status: Single Married (___ years) Separated (___ years) Living as married (___ years) Divorced (___ years) Widowed(___ yrs) Partner name and age (if applicable): _____________________________________________ Children and their ages: ______________________________________________________ Have any of your family members experienced any of the following: Issue Who? Attention/Hyperactivity Problems _________________________ Anxiety _________________________ Panic Attacks _________________________ Obsessive/Compulsive Behavior _________________________ Depression _________________________ Manic Depression (Bipolar) _________________________ Schizophrenia _________________________ Anger Management Problems _________________________ Abusive Behavior _________________________ Suicide Attempts _________________________ Eating Disorder _________________________ Sexual Abuse Survivor _________________________ Alcohol Abuse _________________________ Drug Abuse _________________________ PREVIOUS MENTAL HEALTH TREATMENT Have you had previous counseling? No Yes, when? _______________________________ With whom? ___________________________ For what issue? _________________________ Do you take any medication for mental health reasons? No Yes, which ones, what dosage, and for how long? ___________________________________________________________ Have you ever been hospitalized for a psychiatric reason? Have you ever had substance abuse treatment? Do you participate in any support groups? No No No Yes, when? _______________ Yes, when?_______________________ Yes, which? _________________________ 2 Name: ______________________________________________ SUBSTANCE USE How often do you drink caffeine?____________ How many drinks do you have at a time? _______ How often do you smoke cigarettes? ____________ How many do you smoke per day? _________ How often do you drink alcohol? ____________ How many drinks do you have at a time? _______ Do you use any other recreational substances (marijuana, ecstasy, cocaine, etc)? No Yes, which ones, how often? ______________________________ ______________ Has anyone ever expressed concern about your substance use? No Yes MEDICAL INFORMATION When was your last physical? __________________ Have you ever experienced any of the following medical conditions? Head injury Frequent stomach upset Fainting spells Diabetes Seizures Sexually transmitted disease Chronic pain Migraines Other: ________________ Miscarriage Abortion Asthma Hysterectomy Please list any CURRENT health concerns: __________________________________________ MISCELLANEOUS INFORMATION Employment Employer: __________________________________ Position: ______________________ Length of time in this position: ________ Stress level of this position: Low Medium High Education Highest Level of Education Completed: ______ Are you currently attending school? No Yes Military Service Have you been/are you now in the military? If yes, were you in combat? No No Yes Yes, when/where? ________________________________ Legal Have you ever been convicted of a felony? No Yes, what/when? ______________________ Are you currently involved in any divorce or child custody proceedings? No Yes, please explain __________________________________________________________________ Social Are you involved in any type of spiritual practice? No Yes, which? _____________________ Do you have a local support network (friends, family, church, etc)? Race (optional) _______________ No Yes Sexual Orientation (optional) __________________ SCHOOL FUNCTIONING (CHILDREN ONLY) Child’s year (ex., 5th grade): _____________Child’s academic performance (As, Bs, etc): _________ Has there been a drop in grades recently? No Yes Child’s behavior and/or attendance problems: _______________________________________ Has there been an increase in behavior problems at school recently? Is there any special education plan in place? No No Yes Yes, what? _________________________ ***If there is any other information that you would like to provide, please feel free to attach it.*** 3