Let's "hit the ground running."
Help us to know a little about you and what brought you to our office. It's important that you be as honest as you feel comfortable being and take the time to answer every question as thoroughly as possible. By answering these questions you’ll insure that we don’t waste the first few sessions covering “the basics.”
You’ll also feel better understood, and it will help us make the most of our time.
Sign in to Google to save your progress. Learn more
Email *
First & Last Name *
Date of Birth *
MM
/
DD
/
YYYY
Age
Please describe what prompted you to make this appointment:
What would you like to come out of us working together?
What is your best guess of how long it should take to accomplish this?
Clear selection
Imagine we're a few sessions into your treatment:  What's the first thing that you will notice that will let you know that things are getting better?
What have you tried thus far to address this problem?
What do you think is stopping you (or has stopped you) from successfully addressing this problem?
Health Questions
The following questions refer to your Physical Health.
Consider your life from childhood through adulthood and into your recent experiences, which of the following have you had in the past or are you dealing with currently?  (Check ALL that apply)
Infant/Toddler (0-4 yrs)
Early Childhood (5-10 yrs)
Pre-teen / Adolescence (11-17 yrs)
Young Adult (18-30 years)
Adult (30 yrs & up)
None
Illness/Disease
Accidents
Injuries
Surgeries
Hospitalizations
Loss of Consciousness
Convulsions/Seizures
Medical Conditions
Please provide details of the above conditions.  I'm  interested in knowing:     What's the diagnosis?  How old were you when it started?  Was it treated, and by whom?  What was the result (treated? resolved? ongoing?)
Please list any medications you are currently taking, the condition you are taking them for, when you began taking them (or how long), and who prescribed them.
Please list any over the counter supplements or treatments you are currently taking, why you are taking them, and how long you have been taking them.
Please list your current family doctor, their location,  and their phone number.
May we contact your current physician for the purposes of treatment planning?
Clear selection
If you are being seen by any Specialists (oncologist, psychiatrist, physical therapist, etc.) please list their names, phone numbers, and the conditions they are treating you for.
How many hours of sleep do you usually get per day?
Any difficulty falling or staying asleep?
Clear selection
Do you usually feel or seem rested when you awake?
Clear selection
How is your energy level?
Clear selection
How is your appetite?
Clear selection
Has there been a recent change in your appetite?
Clear selection
Mental Health
The following questions refer to your Mental Health.
Please list any prior mental health treatment or psychological testing conducted that have not already been mentioned in the Health section of this form:
How would you describe yourself?
(select all that apply)
Depressed
Overweight
Shallow
Weak
Helpless
Hopeful
Tough-Skinned
Bizarre
Self-critical
Anxious
Shy
Outgoing
Distant
Lost
Poor Memory
Caring
Grieving
Jolly
Friendly
Procrastinating
Underweight
Low Self-Esteem
Hopeless
Poor Concentration
Secretive
Empty
Forgiving
Confused
Helpful
Inept
Sarcastic
Short-fuse
Hyper-active
Passive
Sad
Nervous
Irritable
Precise
Proud
Self-doubting
Dependable
Guilty
Overwhelmed
Clear selection
Have you (the client) been or is he/she now the victim of or witnessed:
Yes
No
Domestic Spousal Abuse / Violence
Physical Abuse
Emotional Abuse
Sexual Abuse or Assault
Clear selection
If the answer to any of the above questions about abuse is "yes," was the abuse reported?
Clear selection
If it was reported, what was the outcome?
Is the abuse still going on?
Clear selection
Have you (the client) ever discussed or attempted suicide?
Clear selection
If "yes," please describe:
Is there a family history of mental health concerns or treatment?
Clear selection
If "yes," please describe:
Some Demographics & History:
A few questions about your life situation and education.
Please list all schools that you have attended, starting with current or most recent:
In general, how do (or how did) you do in the following areas in school:
Very Poor
Poor
Well
Very Well
Adjustment to school?
Academics?
Peers?
Teachers, Principals, or Professors?
Extra Curricular Involvement?
Clear selection
Please list your employment history, starting with the current or most recent.  I'm interested in how long you worked there, the employer, what your job title was, and your reason for leaving.
If you served in the Military, please list the dates, branch of service, your rank, and reason for leaving/current status.
Current Family Income (annually):
Clear selection
Please list any situations that have brought you in contact with the legal system, law enforcement, or the courts.  Please list the date or your approximate age, describe the situation, and describe the outcome:
Family Background
Some information about your Family of Origin.
Family Members  (Check ALL that apply)
Alive
Deceased
Get Along Well
Get Along Poorly
Estranged
Father
Mother
Stepfather
Stepmother
Sibling
Sibling 2
Sibling 3
Sibling 4
Sibling 5
Sibling 6
If your father is alive, what is his current age?  If he is deceased, what was his age at death and cause of death?
If your stepfather is alive, what is his current age?  If he is deceased, what was his age at death and cause of death?
If your mother is alive, what is her current age?  If she is deceased, what was her age at death and cause of death?
If your stepmother is alive, what is her current age?  If she is deceased, what was her age at death and cause of death?
If your siblings are alive, what is their current age?   If they are deceased, what was their age at death and cause of death?
Current Family Structure:     Please list all individuals who currently live with you.  Include any information about foster home placement, or custody arrangements for separated / divorced parents.
Relationships History
Some information about current and past romantic involvements.
Marital & Relationship History:   Please indicate your current relationship status:
Clear selection
If you are in a relationship, how did you meet your Current Spouse/Partner?
Current Spouse/Partner:   when did you get married and how long have you been together?
Describe your current relationship:
Positive things about your Current Spouse/Partner:
Negative things about your Current Spouse/Partner:
Previous Spouse/Partner:  When did you get together/get married, and how long were you together?
Describe your Previous Relationship:
Positive things about your Previous Spouse/Partner:
Negative things about your Previous Spouse/Partner:
If you are Divorced, what let up to the divorce?
Children
A few questions about your children, if you have them.
Do you have Children?
Clear selection
Please check all that apply:
1
2
3
4
5
6 or more
Biological Children
Step-Children
Adopted Children
Foster Children
Deceased Children
Clear selection
Please list your Children's Names, Dates of Birth, & Ages:
For the children listed above:  Please list the School Attended Currently, Grade, and any Difficulties or Problems they are experiencing.
Lifestyle choices.
 This section refers to use of substances that are NOT prescribed by Doctors or are used recreationally.
Indicate whether you use or used in the past any of the following, and the ages at which you used them:
As a Child
As a Teen
Currently Use / Used Recently
Past - I decided to stop.
Past - I stopped with treatment
Past - Court / Law Enforcement Involvement
Caffeine
Nicotine
Alcohol
Amphetamine (Speed, Uppers)
Depressants (Xanax, Klonopin)
Inhalants (Whip-its, Paint, Glue)
Marijuana (Pot, Weed, Dabs, Edibles)
Narcotics (Vicodin, OxyContin, Percocet, Heroin)
Cocaine (blow, crack)
Methamphetamine (meth, crank, ice, glass, crystal)
Ecstasy (Molly, MDMA)
Is there a drug or substance you've used that isn't listed above?  If so, please explain:
Has anyone complained about your drug use?  If so, who?
Have you ever felt guilty over your drinking / drug use?
Clear selection
Do you typically have a drink to get going in the morning?
Clear selection
Have you ever consumed alcohol while working without the approval of your employer?
Clear selection
Has your drug / alcohol use resulted in problems at work, home or personal life?
Clear selection
Have you ever blacked out from alcohol / drug use?
Clear selection
More than 3 times?
Clear selection
How many times have you been charged with DUI / OVI?
Stress
Some questions about Chronic (ongoing) and Acute (immediate time limited) Stress.
Please list any ongoing situations or events that produce stress for you or your family:
Please list any stressful situations that have recently begun and may be effecting you or your family.
Support
Let's talk about your support system.
Please list any individuals in your life who you draw support from:
Please list any organizations, clubs, or groups that provide you with support:
Please list any hobbies or activities that you engage in, in order to reduce your Stress:
Religious & Spiritual Beliefs
Let's talk about spirituality.
What was your childhood upbringing or experience with religion?  Did your family have a particular religious belief system?
What is your current religious belief system or affiliation, if you have one?
To what degree do your spiritual and religious beliefs impact you?
Is there anything else you feel it's important for me to know?
Thank You!
Thank you for taking the time to fill out this form.  All information contained within is confidential and can only be released with a valid and signed release of information.
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms