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Transcript
2016 1 Avalon Social Services, Inc. BCJP Counseling Services Intake Client Name: ___________________________________ Probation Officer: _________________________________ Date: _____________ Counselor: ___________________________________________ Location:______________ DOB: ______________ Session Start Time: ______________________ Session End Time: ___________________ DOB _________Gender: M F Age: _______ Grade/Education Level: ____ Legal Guardian: _______________ DSM-V Diagnosis: Specifics including Severity ICD-10 Code(s)_____ _____ ____ _____ Diagnosis:______________________________________________________________________________ ______________________________________________________________________________________ __________________________________________________________________________ Presenting Problem History Reason for Referral: ______________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ Legal Involvement/History: ________________________________________________________________________ __________________________ ____________________________________________________________________ ______________________________________________________________________________________________ Duration of Symptoms: ___________________________________________________________________________ ______________________________________________________________________________________________ History of Present Illness/Problem: __________________________________________________________________ _______________________________________________________________________________________________ Attempts to Resolve Current problem/Situation: ________________________________________________________ _______________________________________________________________________________________________ Additional Family Members to participate in Treatment: __________________________________________________ Sent to Probation: Hand Delivered Faxed Mailed Date: 2016 2 Chemical Dependency Issues: _______________________________________________________________________ _______________________________________________________________________________________________ Psychiatric History Psychiatric Hospitalizations: _______________________________________________________________________ Past Counseling Experience: _______________________________________________________________________ (Year/Date) Duration Family History of Mental Illness/Related Symptoms/Substance Abuse/ Treatment: History of physical or sexual abuse: _____________________________________________________ Depression: ___________________________ Anxiety/Panic/Phobia: _________________________ Mania/Bipolar: ________________________ Delusional/Psychotic: _________________________ ADHD/Conduct Disorder: _______________ Mental Retardation: ___________________________ Learning Disability: ____________________ Dementia: ___________________________________ Alcohol: ______________________________ Marijuana: __________________________________ Cocaine: _____________________________ Narcotics: ___________________________________ Hallucinogens: ________________________ Amphetamines: _______________________________ Sedatives: ____________________________ Inhalants: ___________________________________ Prescription Drugs: _____________________ Other: ______________________________________ Family/Social/Developmental History Pregnancy Complications: ________________________________________________________________________ Birth place, Weight, Complications: _________________________________________________________________ Birth Order and Siblings: __________________________________________________________________________ Parental Discipline: ______________________________________________________________________________ Parent’s Marital History: __________________________________________________________________________ ______________________________________________________________________________________________ Developmental History/Significant Events: ____________________________________________________________ ______________________________________________________________________________________________ Milestones: Walk: ____________ Talk: __________ Toilet Training: ____________ Other: __________________ Academic History: _______________________________________________________________________________ Ever Suspended: _____________________________ Grades Repeated: ____________________________________ Grades: Elementary: ___________ Middle: ____________ High: ___________ College: ______________________ Current School & District: _________________________________ Teacher: _______________________________ Marital Status: Single Married Significant Other Divorced Widowed Remarried Sent to Probation: Hand Delivered Faxed Mailed Date: 2016 3 Relationships/Marriage/Children: ___________________________________________________________________ ______________________________________________________________________________________________ Alcohol and Drug Use History (age of onset, amount, frequency, cessation) Alcohol Cocaine Prescription Drugs Marijuana Sedatives Tobacco/Nicotine Inhalents Amphetamines Narcotics Other: ________________________________ Comments: _____________________________________________________________________________________ Current family Functioning: ________________________________________________________________________ ______________________________________________________________________________________________ Financial Difficulties: _____________________________________________________________________________ Client strengths/Coping Mechanisms/ Support System: __________________________________________________ ______________________________________________________________________________________________ Medical History Pregnancy/Birth Complications Familial Left-Handedness Loss of Consciousness Head Injury Stroke Seizures Surgeries Loss of Coordination Fainting/Dizziness Hypertension Diabetes Kidney/Liver Dis. Thyroid Problems Weakness/Numbing Shaking/Tremor Allergies Migrains/Headaches Infections Toxic Exposure Cancer/Radiation Blackouts Malnutrition Hearing Changes Developmental Dis. Electrical Accidents Medication UTI/Impaction Neurological Illness Memory Changes Visual Changes Abnormal Neuroimaging Other Describe any identified: ___________________________________________________________________________ ______________________________________________________________________________________________ Current Medication/Recent Changes in Medication: _____________________________________________________ Additional Information: __________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ ____________________________________________ Counselor Sent to Probation: Hand Delivered Faxed _____________________________________ Date Mailed Date: 2016 Sent to Probation: 4 Hand Delivered Faxed Mailed Date:
