Download intake evaluation - Megan A. Wuest, MS, LPA

Megan A. Wuest, MS, LPA
1598 Pearl Street
Eugene, OR 97401
ADULT INTAKE INFORMATION: To be completed by client
Client’s Name:
Today’s Date ____________
Address:
City, State, Zip: ___________________________
Home phone:
_____________Work phone:
Social Security (ID) Number:
___
May we leave messages for you at home?  Yes
Gender:  M
F
Age:
__________
 No At work?
Birth Date:
 Yes  No
Marital Status:
Others Living in Home (name, birth date, relationship to client)
____________________________________________________________________________________________
______________________________________________________________________________________
Education: __
Occupation: __
_________________________________
________________________________________
Employer/School:
____________________
INSURANCE INFORMATION
Name of Insured:
Insured Date of Birth:
_______
Address of Insured:
City, State, Zip:
_______
Relationship of Client to Insured:
Insurance Company:
Insurance Identification Number:
Secondary insurance:
Name of Secondary Insured:
Employer of Insured:____
Phone:
Group Number:
Phone:
Insured Date of Birth:
_______
______________
_______
_____________
______________
Secondary Company Address:
City, State, Zip:
______________
Secondary Identification Number:
Group Number:
_______
PATIENT OR AUTHORIZED PERSON’S SIGNATURE
I authorize the release of any medical or other information necessary to process a claim. I also request payment of government
benefits either to myself or to the party who accepts assignment. I authorize payment of medical benefits to the provider of
services.
Date:
FOR OFFICE USE ONLY
DIAGNOSIS:
__________________
Briefly describe the problem that brought you here today?
Symptoms
check the behaviors/symptoms that occur to you more often than you would like:
______fatigue
______sexual difficulties
______self harm (cutting, etc.)
______anger
______heart palpitations
______high blood pressure
______avoiding people
______suicidal thoughts
______problem concentrating
______disorientation
______trembling
______loneliness
______dizziness
______worrying
______mood shifts
______eating disorder
______elevated mood
______reoccurring thoughts
______hallucinations
______depression
______harm to others
______anxiety
______sleeping problems
______irritability
______chest pain
______thoughts disorganized
______judgment errors
______speech problems
______withdrawing
______memory impairment
______drug dependence
______ other (specify)
______panic attacks
______phobias/fears
Substance Use
Please describe client’s frequency of use:
Current
Past
No
Alcohol: _____________________________________________________________________________________
Caffeine: ____________________________________________________________________________________
Tobacco: ____________________________________________________________________________________
Marijuana: __________________________________________________________________________________
Other: ______________________________________________________________________________________
Have you received personal counseling in the past? Yes _______ No _______
If so, what made it a positive or negative experience? __________________________________________________
______________________________________________________________________________________________
Are you receiving counseling services at present? Yes _____ No ______
What would you like to accomplish in therapy (how would you know if therapy was effective)?
_______________________________________________________________________________________________
Whom do you consider to be your support network? _____________________________________________________
_______________________________________________________________________________________________
What do you do to give care to yourself (physically, mentally, and emotionally)?
________________________________________________________________________________________________
Please list the 5 most empowering/positive events/memories that shape the life you live today:
1: ______________________________________________________________________________________________
2: ______________________________________________________________________________________________
3: _____________________________________________________________________________________________
4: _____________________________________________________________________________________________
5: _____________________________________________________________________________________________
Please list the 5 most disturbing events/memories that shape the life you live today:
1: ______________________________________________________________________________________________
2: ______________________________________________________________________________________________
3: _____________________________________________________________________________________________
4: _____________________________________________________________________________________________
5: _____________________________________________________________________________________________
Medical History
Primary physician’s name: ______________________________________________________________________
Primary physician’s address: _____________________________________________________________________
What prescription medications (and dosages) are you taking at present, and for what purpose?
Medication
Purpose
____________________
_________________________________________________________________
____________________
_________________________________________________________________
____________________
_________________________________________________________________
Have you ever had a head injury?
Have you ever had seizures?
No _____ Yes _____
No _____ Yes _____
Family History
With a few words, please briefly describe your mother (or mother figure):
________________________________________________________________________________________
Did your mother have any problems (e.g., alcoholism, violence, etc.) that may have affected your childhood
development? Yes ______ No ______
If Yes, please describe) _______________________________________________________
With a few words, please briefly describe your father (or father figure):
_________________________________________________________________________________
Did your father have any problems (e.g., alcoholism, violence, etc.) that may have affected your childhood
development? Yes ______ No ______
If Yes, please describe) ___________________________________________________________
One word description of your 3 greatest personal strengths:
(1)_________________________ (2) __________________________(3) __________________________
One word description of your 3 greatest personal challenges:
(1)_________________________ (2) __________________________(3) __________________________
Describe legal history (i.e., criminal, probation, divorce, child custody, etc.) ___________________________
EMDR Screening Questions
Please indicate to what degree the experience described in the following statements applies to you by circling the number to show
what % of time you have the experience.
1. Some people have the experience of finding themselves in a place and having no idea how they got there.
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
2. Some people have the experience of finding new things among their belongings that they don’t recall buying.
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
3. Some people have the experience of feeling as though they are standing next to themselves or watching themselves - almost as
though they were looking at another person.
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
4. Some people are told that they sometimes do not recognize family or friends.
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
5. Some people have the experience of feeling that other people, objects, and the world around them are not real.
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
6. Some people have the experience that their body does not belong to them.
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
7. Some people find that in one situation they may act so differently compared with another situation that they almost feel as if they
were two different people.
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
8. Some people hear voices inside their head that tell them to do things or comment on things they are doing.
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Thoughts
Please place a check next to any of the following negative self-beliefs that occur to you more often than you would like
RESPONSIBILITY( I’m defective)
SAFETY/VULNERABILITY
____I don’t deserve love
____I cannot be trusted
____I am a bad person
____I cannot trust myself
____I am terrible
____I cannot trust my judgment
____I am worthless (inadequate)
____I cannot trust anyone
____I am shameful
____I cannot protect myself
____I am not lovable
____I am in danger
____I am not good enough
____It’s not OK to feel (show) my emotions
____I deserve only bad things
____I cannot stand up for myself
____I am permanently damaged
____I cannot let it out
____I am ugly (my body is shameful)
____I do not deserve . . .
CONTROL/CHOICES
____I am stupid (not smart enough)
____I am not in control
____I am insignificant (unimportant)
____I am powerless (helpless)
____I am a disappointment
____I am weak
____I deserve to die
____I cannot get what I want
____I deserve to be miserable
____I am a failure (will fail)
____I’m different (don’t belong)
____I cannot do . . .
____I cannot succeed
RESPONSIBITY (I did something wrong)
____I have to be perfect (please everyone)
____I should have done something
____I cannot stand it
____I did something wrong
____I cannot trust anyone
____I should have known better