Download Peace of Mind Psychological Services, LLC

Peace Of Mind Psychological Services, LLC
Client History Form
Date:
______________________________
Name:
______________________________
D.O.B.:
____________________
Address:
______________________________
Age
____________________
______________________________
Email:
____________________
Home
Phone:
Emergency
Contact:
Cell Phone:
______________________________
____________________
Phone
Number:
______________________________
____________________
Patient Communication Preferences:
Our office may need to contact you to schedule and/or reschedule appointments, to schedule follow-up
visits and other such administrative issues. To ensure that your privacy is maintained to the fullest
extent possible, please select the method by which our office can contact you.
Home phone- Leave message? Yes________ No_________
Cell phone- Leave message? Yes________ No_________
Work phone- Leave message? Yes________ No_________
Email?
Yes________ No_________
PARENT/GUARDIAN INFORMATION
Names
Relation to child
Contact Number
______________________ _____________________
______________________ _____________________
______________________ _____________________
__________________________
__________________________
__________________________
If parents are divorced: Who is the “custodial” parent? ________________________________
Frequency of visitation with “non-custodial” parent? __________________________________
SIBLINGS
Name
Age
_________________________________
_________________________________
_________________________________
Primary Residence
___________________
___________________
___________________
__________________
__________________
__________________
9810-A Medlock Bridge Road Suite 103-A
John’s Creek, Georgia 30097
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Peace Of Mind Psychological Services, LLC
Quality of Family Relationships: Include all people who live in the home
Name
Age
Relationship
Quality of Relationships
(poor, fair, good)
___________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
___________________________________________________________________________________
What concerns brought you in today? ______________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
MENTAL HEALTH HISTORY
Has your child ever been diagnosed with a mental health diagnosis? If so, what?
______________________________________________________________________________
Has your child ever received mental health treatment?
Counselor Name
Dates
Reason for Treatment
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Psychological Evaluation
Date
Diagnosis (es)
Name of Assessor
_________________________________________________________________________________
_________________________________________________________________________________
Psychiatric Hospitalization
Date
Reason for Treatment
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Name of Psychiatrist (if applicable)
_________________________________________________________________________________
Name of current psychiatric medications
_________________________________________________________________________________
Name of past psychiatric medications
_________________________________________________________________________________
Is there any history of self-injury (i.e., hitting, biting, cutting) or suicidal behavior?
__________________________________________________________________________________
9810-A Medlock Bridge Road Suite 103-A
John’s Creek, Georgia 30097
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Peace Of Mind Psychological Services, LLC
Family History of Mental Health Problems (check all applicable areas)
Mother
Father
Aunt
Uncle
Cousins
Grandparents
Anxiety
Depression
Bipolar Disorder
Schizophrenia
ADHD
Drugs/Alcohol
Eating Disorder
Post-Traumatic
Stress Disorder
Behavioral Checklist
0-Not a Problem, 1-Mild Difficulty (Occurs less than weekly), 2-Moderate (Occurs at least 1-2 times a week), 3-Severe Problem (Occurs several
times a week)
Behavior
Severity
Behavior
Severity
Behavior
Severity
Alcohol Abuse
0, 1, 2, 3
Irritability
0, 1, 2, 3
Loses Things
0, 1, 2, 3
Drug Abuse
0, 1, 2, 3
Destruction to
property
0, 1, 2, 3
Poor Organizational
Skills
0, 1, 2, 3
Social/Relational
0, 1, 2, 3
Lying
0, 1, 2, 3
Easily Distracted
0, 1, 2, 3
Academic
0, 1, 2, 3
Run Away
0, 1, 2, 3
0, 1, 2, 3
Physical Aggression
0, 1, 2, 3
Steals
0, 1, 2, 3
Difficulty
communicating
clearly
Impulsive
Verbal Aggression
Bullying
0, 1, 2, 3
0, 1, 2, 3
Inattention
Fidgety
0, 1, 2, 3
0, 1, 2, 3
0, 1, 2, 3
0, 1, 2, 3
Losing temper easily
Argumentative
Defiant
0, 1, 2, 3
0, 1, 2, 3
0, 1, 2, 3
Fails to finish things
Talks excessively
Forgetfulness
0, 1, 2, 3
0, 1, 2, 3
0, 1, 2, 3
Easily Annoyed by
others
Difficulty sleeping
0, 1, 2, 3
0, 1, 2, 3
0, 1, 2, 3
Self-harm attempts
0, 1, 2, 3
Nightmares
0, 1, 2, 3
0, 1, 2, 3
Separation anxiety
0, 1, 2, 3
Poor appetite
Lack of physical
boundaries
0, 1, 2, 3
0, 1, 2, 3
Interrupts
others/Blurts out
Hears voices that
are not there
Sees things that are
not there
Fear/Phobia
Excessive worry
Tired/Fatigued
Unpredictable
Moods
Sadness
Low self-esteem
Thoughts of selfharm
Thoughts of death
0, 1, 2, 3
0, 1, 2, 3
Heart racing
Sexual behavior
problems
0, 1, 2, 3
0, 1, 2, 3
0, 1, 2, 3
0, 1, 2, 3
0, 1, 2, 3
0, 1, 2, 3
0, 1, 2, 3
0, 1, 2, 3
How would you describe your child? __________________________________________________
______________________________________________________________________________
9810-A Medlock Bridge Road Suite 103-A
John’s Creek, Georgia 30097
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Peace Of Mind Psychological Services, LLC
What are his/her strengths?_________________________________________________________
______________________________________________________________________________
What activities does he/she enjoy? ___________________________________________________
Participate in?_____________________________________________________________
How does your child get along with peers? ______________________________________________
______________________________________________________________________________
Does your child have any history of abuse? (i.e., sexual, physical, emotional) If so give specific details
(i.e., dates, nature of abuse, was there legal involvement?) __________________________________
______________________________________________________________________________
______________________________________________________________________________
Has your child ever witnessed any domestic violence, violence which led to injury or death, or loss?
______________________________________________________________________________
______________________________________________________________________________
How does your child manage stress/emotional distress? ____________________________________
______________________________________________________________________________
Additional comments _____________________________________________________________
______________________________________________________________________________
MEDICAL HISTORY
Pediatrician_____________________________________________________________________
Current Medical Problems (including allergies) __________________________________________
______________________________________________________________________________
Past Medical Problems (including surgeries) _____________________________________________
______________________________________________________________________________
Current Medication
Dosage
Frequency
Prescribed by
Reason prescribed
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
9810-A Medlock Bridge Road Suite 103-A
John’s Creek, Georgia 30097
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Peace Of Mind Psychological Services, LLC
Has your child ever sustained a head injury? _____________________________________________
How is your child’s appetite? ________________________________________________________
How is your child’s sleeping? ________________________________________________________
DEVELOPMENTAL HISTORY
What was the length of the pregnancy? __________________
Weight at birth? ____________
Were there any complications during the pregnancy with your child?___________________________
______________________________________________________________________________
Was there any maternal drug or alcohol abuse? __________________________________________
Developmental milestones (provide specific ages in months)
Crawl_______ Walk______ First words_____ Combined Words______ Toilet Trained________
Did you have any concerns about your child as a toddler (i.e., seeing, hearing, social interactions,
learning, sleeping, eating?) _________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
EDUCATIONAL
Current school __________________________________________ Grade __________________
Current grades __________________________________________________________________
Academic strengths _______________________________________________________________
Academic Weaknesses ____________________________________________________________
Has your child ever been retained? Is so when ___________________________________________
Does your child receive any academic accommodations (IEP, 504 plan, EIP) ______________________
______________________________________________________________________________
Any other services (i.e., speech, occupational, physical therapy) ______________________________
______________________________________________________________________________
9810-A Medlock Bridge Road Suite 103-A
John’s Creek, Georgia 30097
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Peace Of Mind Psychological Services, LLC
Behavioral Concerns (including suspensions and detentions) _________________________________
______________________________________________________________________________
______________________________________________________________________________
SPIRITUAL
Is faith/religion meaningful in your life? ________________________________________________
If yes, do you have a faith/church affiliation?_____________________________________________
ALCOHOL AND DRUG HISTORY
Is your child/teen currently using drugs or alcohol? If so, please give specific details __________
______________________________________________________________________________
______________________________________________________________________________
Is there any history of substance abuse treatment? _______________________________________
______________________________________________________________________________
______________________________________________________________________________
LEGAL HISTORY
Has your child ever been arrested? ___________________________________________________
Charge/Date ___________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Current probations/terms __________________________________________________________
Past probation/terms _____________________________________________________________
Any other legal problems? __________________________________________________________
Thank you for completing this form and I look forward to working with you.
Dr. Brianna Gaynor
9810-A Medlock Bridge Road Suite 103-A
John’s Creek, Georgia 30097
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