Download No Yes, when? - Lauren Dahl, LCSW

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? ________________________________________________________
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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? _________________________
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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.***
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