Client History Packet for Adult
Please complete the following form.  Your responses will be viewed by your clinician.
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Email *
Date *
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Time *
Time
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Who is completing this document? *
Required
Client's Name *
Date of Birth *
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Gender (please include preferred pronouns) *
How did you hear about Theraplace? *
Name of Primary Care Physician and Clinic *
Do you give permission for ongoing regular updates to be provided to your Primary Care Physician? *
Primary reason(s) for seeking services *
Highest Level of Education *
Employment Status *
Required
Additional Information Relating to Education or Employment (area of study, job title, employer, etc.) *
Living Situation  - Please choose all that apply. *
Required
With whom do you live? List people and pets if applicable. *
How important are spiritual or religious beliefs to you? *
Not Important
Very Important
Are you affiliated with a spiritual or religious group? If yes, which one? Type "no" if you are not affiliated with a spiritual or religious group. *
Would you like spiritual or religious beliefs incorporated into counseling? *
To which cultural or ethnic group do you belong (Ex. Caucasian, African American, Native American, Hispanic, Somali, etc.)? *
Are you experiencing any problems due to culture or ethnicity? If yes, please describe. Type "no" if you are not experiencing any problems due to culture or ethnicity. *
Other cultural/ethnic information:
Describe areas of interest or hobbies (ex. reading, crafts, physical fitness, outdoor activities, walking, travelling, volunteering). *
Describe your strengths and resources.  What do you do well?  Who do you consider supportive (pet, family, friend, therapist)? Which areas of your life are stable? *
Medical/Physical Health - Please check all that apply. *
Required
Please describe any recent changes in your physical health.  Type "none" if no recent changes have occurred. *
Do you exercise? If yes, please describe what kind of exercise, how many days per week and how much time each day.  Type "no" if you do not exercise. *
When your mother was pregnant with you, were there any complications during the pregnancy or birth? If yes, please explain.  Type "no" if there were no complications. *
Please describe your family medical history (ex. history of cancer, diabetes, high blood pressure, etc.). *
Please list currently prescribed medication, including name of prescribing physician.  Indicate if you experience any side effects from currently prescribed medication.  Type "none" if you are not currently prescribed medication. *
Please list any current over-the-counter medication (ie. medication that does not require a prescription from a physician), including vitamins or herbal supplements.  Indicate if you experienced any side effects from prescribed medication.  Type "none" if you are not taking over-the-counter medication. *
Please list past prescribed medication, including name of prescribing physician.  Indicate if you experienced any side effects from prescribed medication.  Type "none" if you have not been prescribed medication. *
Are you allergic to medication or drugs?  If yes, please describe.  Type "no" if you have no allergies to medication or drugs. *
Are you involved in any active legal cases (ex. traffic, civil, criminal?  If yes, please describe.  Indicate charges and court hearing/trial dates.  Type "no" if you are not involved in any active legal cases. *
Are you currently on parole?  If yes, please list name of parole officer and monitoring county.  Type "no" if you are not currently on parole. *
Please describe any other legal information you would like your clinican to know (ex. I will be returning to court to address custody of my child).
Do you have military experience?  If yes, please describe (ex. branch of military, date enlisted, date discharged, type of discharge, rank at discharge).  Type "no" if you have no current or past military experience. *
Chemical Use History - Check any that you have used in the past or currently use.
Used within past 7 days
Used within past 30 days
Used within past 90 days
Used within past 6 months
Used within past year
Used within past 5 years
Used in past, more than 5 years ago
Alcohol
Barbiturates
Cocaine
Ecstasy
Heroin
LSD or Hallucinogens
Marijuana
Methadone
Methamphetamine
Pain killers (not as prescribed)
Stimulants (pills)
Tranquilizer/sleeping pills
Other
How many caffeinated beverages do you drink per day? *
Have you ever smoked cigarettes? If Yes, please answer the following questions.  If No, please skip to the next required questions. *
Do you currently smoke cigarettes? If yes, how many packs per day on average? How many years?
If you do not currently smoke cigarettes, how many years ago did you smoke?  When did you quit?  How did you quit?
Have you ever been treated for alcohol or drug use or abuse? If yes, for which substances, where were you treated, and when?  Type "no" if you have never been treated for alcohol or drug use. *
CAGE AID - Question 1 of 4 - In the last three months, have you felt you should cut down or stop drinking or using drugs? *
CAGE AID - Question 2 of 4 - In the last three months, has anyone annoyed you or gotten on your nerves by telling you to cut down or stop drinking or using drugs? *
CAGE AID - Question 3 of 4 - In the last three months, have you felt guilty or bad about how much you drink or use drugs? *
CAGE AID - Question 4 of 4 - In the last three months, have you been waking up wanting to have an alcoholic drink or use drugs? *
Does anyone in your family have past or present substance use?  If yes, please indicate which substance(s) and the family member's relationship to you.  Type "no" if no family members have a history of substance use. *
Childhood/Adolescent Maltreatment or Abuse - Please check all that apply: *
Required
Childhood Development *
Developmental milestones met
Developmental delay
Social/Emotional
Cognitive (learning/thinking/problem-solving)
Language/Communication
Movement/Physical
Childhood Maltreatment or Abuse - Additional information you would like your clinician to know.
Please list immediate family members, including whether they are living or deceased, and approximate ages (ex. parent, sibling, step parent, grandparent, child, spouse, significant other). *
Any additional information about your family background you would like to share (ex. adopted, moved a lot, happy childhood, turbulent childhood, split household, lived in the city, lived in a rural area, raised by grandparents, mother's occupation)?
Parental Information - Please check all that apply. *
Required
Relationship Status - Please check all that apply. *
Required
Children in home *
Required
Sexual orientation *
Required
Adult Trauma History - Please check all that apply. *
Required
Do you have a history of being a sexual predator? *
Current Symptoms - Please check any behaviors and symptoms that you experience. *
Required
Briefly discuss how the above symptoms affect your functioning at home, school, work, in the community or socially. *
History of symptoms.  Please describe when your symptoms started, when they worsen or improve, etc. *
Symptom Scaling Questionnaire - Circle one number between 0 and 10 to describe each category. *
0 (none)
1
2
3
4
5
6
7
8
9
10 (Severe)
Sadness
Suicidal thoughts
Anxiety
Frustration/anger
Symptom Scaling Questionnaire - Circle one number between 0 and 10 to describe each category. *
0 (poor)
1
2
3
4
5
6
7
8
9
10 (great)
Sleep
Interest/pleasure in life
Appetite
Motivation
Concentration
Energy level
Overall life satisfaction
Work/school satisfaction
Relationship with friends
Relationship with partner(s)
Relationship with family
Suicide Risk Assessment - Have you ever had feelings that you didn't want to live? If Yes, please answer the following questions.  If No, please skip to the next required question. *
Suicide Risk Assessment - Do you currently feel that you don't want to live?
Clear selection
Suicide Risk Assessment - How often do you have thoughts that you don't want to live?
Suicide Risk Assessment - When was the last time you had thoughts of dying?
Suicide Risk Assessment - Has anything happened recently to make you feel this way?
Suicide Risk Assessment - On a scale of 0-10, how strong is your desire to kill yourself currently?
Clear selection
Suicide Risk Assessment - Would anything make it better?
Suicide Risk Assessment - Have you ever thought about how you would kill yourself?
Clear selection
Suicide Risk Assessment - Is the method you would use readily available?
Clear selection
Suicide Risk Assessment - Have you planned a time for this?
Clear selection
Suicide Risk Assessment - Do you feel hopeless and/or worthless? *
Suicide Risk Assessment - Do you have access to firearms? *
Suicide Risk Assessment - Have you ever tried to kill or harm yourself before?  If yes, please explain.  Type "no" if you have never tried to harm yourself. *
Please describe any history of suicidal ideation or self harm.  Type "none" if you have not experienced suicidal ideation or self harm. *
History of Treatment - Please check all that apply. *
Required
Please list any previous mental health diagnoses.  Type "none" if you have never received a mental health diagnosis. *
History of Treatment for Family and Significant Others - Please check all that apply. *
Required
Please list any previous mental health diagnoses for Family Members or Significant Others.  Type "none" if your family members or significant others have never received a mental health diagnosis. *
DSM V Severity Measure for Depression - During the PAST 7 DAYS, I have... *
0 (0 days)
1 (1-3 days)
2 (4-6 days)
3 (7 days)
Had little interest or pleasure in doing things
Felt down, depressed or hopeless
Had trouble falling or staying asleep, or sleeping too much
Felt tired or had little energy
Had poor appetite or overeating
Felt bad about myself - or that I am a failure or have let myself or my family down
Had trouble concentrating on things
Moved or spoken so slowly that other people could have noticed - or the opposite - been so fidgety or restless that I have been moving around a lot more than usual
Had thoughts that I would be better off dead or hurting myself in some way
DSM V Severity Measure for Generalized Anxiety Disorder - During the PAST 7 DAYS, I have... *
0 (0 days)
1 (1-2 days)
2 (3-4 days)
3 (5-6 days)
4 (7 days)
Felt moments of sudden terror, fear or fright
Felt anxious, worried or nervous
Had thoughts of bad things happening, such as family tragedy, ill health, loss of a job or accidents
Felt a racing heart, sweaty, trouble breathing, faint or shaky
Felt tense muscles, felt on edge or restless or had trouble relaxing or trouble sleeping
Avoided, or did not approach or enter, situations about which I worry
Left situations early or participated only minimally due to worries
Spent lots of time making decisions, putting off making decisions or preparing for situations, due to worries
Sought reassurance from others due to worries
Needed help to cope with anxiety (ex. alcohol, medication, superstitious objects, other people)
WHODAS 2.0 - This questionnaire asks about difficulties due to health/mental health conditions.  Health conditions include diseases or illness, other health problems that may be short or long lasting, mental or emotional problems, and problems with alcohol or drugs.  IN THE LAST 30 DAYS, how much difficulty did you have in the following areas: *
None
Mild
Moderate
Severe
Extreme or cannot do
Standing for long periods, such as 30 minutes
Taking care of your household responsibilities
Learning a new task (ex. learning to get to a new place)
Joining in community activities (ex. festivites, religious or other activities) in the same way as anyone else can
How much have you been emotionally affected by your health condition
Concentrating on doing something for ten minutes
Walking a long distance such as a kilometer (0.621 miles)
Washing your whole body
Getting dressed
Dealing with people you do not know
Maintaining a friendship
Your day-to-day work
WHODAS 2.0 - Overall in the past 30 days, how many days were these difficulties present? *
WHODAS 2.0 - In the past 30 days, how many days were you totally unable to carry out your usual activities or work because of any health condition? *
WHODAS 2.0 - In the past 30 days, not counting the days that you were totally unable, for how many days did you cut back or reduce your usual activities or work because of any health condition? *
Any additional information that would assist us in understanding your concerns or problems? *
What are your goals for therapy? *
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