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Personal History - Adult

Jewish Family and Career Services of Atlanta
4549 Chamblee Dunwoody Road
Phone 770.677.9389
Fax 770.677.9400
 Client Information
  First Name:  * Last Name:  *  
           
  Date of Birth:  * Birth Sex: 
* 
         
  Address: City:  
  State: Zip Code :  
  Phone No:  
Household Information
Number of members in Household    (please include yourself)
Household Member Information (please include yourself)
  Name Gender Age Relationship to client Quality of relationship
Household Member 1:
Household Member 2:
Household Member 3:
Household Member 4:
Household Member 5:
Household Member 6:
Household Member 7:
Household Member 8:
Do you have any children that live outside of the home?    
If yes, how many and whom do they live with?    
Total Household Income
Place of Birth
Number of Siblings
Are you in contact with any extended family members?
Highest Level of Education
Professional Licensure or Certifications
Are you currently employed?
Name of Employer
Position/Title
Length of time with this employer
Medical Information
Current Medications
  Name of Medication Dosage/Frequency Reason Prescribing MD
1.
2.
3.
4.
5.
6.
Other Medication/Over-the-Counter/Herbals:
Any known allergies
If yes, please describe:
Mental Health History
Symptom History - Check any of the following problems that you have experienced in the past six (6) months:
Lack of appetite   Excessive drinking   Anger management  
Problem drug use   Nervousness   Fatigue  
Panic attacks   Anxiety   Loneliness  
Nightmares   Intrusive thoughts   Sleep disturbance  
Headaches   Sleep problems   Appetite disturbances  
Stomach problems   Low self-esteem   Relationship problems  
Difficulty concentrating   Flashbacks   Depression  
Bowel problems   Bladder Control Problems   Fears/Phobias  
Feelings of unreality   Obsessive thoughts   Compulsive behaviors  
Marital problems   Family problems   Difficulty trusting  
Difficulty relaxing   Isolation   Social withdrawal  
Guilt or Shame   Hopelessness   Sadness/Loss  
Easily annoyed   Lose track of time   Confusion  
Chest pain   Pain (where?):    
Other comments about symptoms:
Have you ever been in counseling before:
If yes, did you find it helpful?
Have you ever been hospitalized for mental health reasons?
Please list hospitals and dates:
Have you ever had thoughts of harming yourself, or suicidal thoughts?
Have you ever had thoughts of harming others?
Have you ever been prescribed any medications for mental health concerns?
Please list all medication you have been prescribed:
  Name of Medication Dosage/Frequency Reason Prescribing MD
1.
2.
3.
4.
Substance Abuse History
How often do you drink alcohol?
Daily   Weekly   Weekends Only  
2-3 times/month     
Other comments about alcohol use:
Have you ever used any other drug, such as marijuana, cocaine, meth, LSD, heroin or any other street or prescription drugs that were not prescribed to you?
Please list which the drugs you have used in the past 10 years:
  Drug Name Last Used (Month/Year)
1.
2.
3.
4.
5.
Have you ever had a DUI?
How many and dates of offense?
Have you ever been treated for alcohol or drug abuse?
Have you ever attended AA/NA or any other peer support recovery group?
Does anyone in your family have a problem drinking and/or using drugs?
If so, who?
Domestic Relationship History
Are you currently in a committed relationship?
If yes, for how long?
Has your partner done any of the following to you or a loved one?
  To you? To someone else? If someone else, who?
Call you names or put down
Wants to always know where whereabouts
Force to give over paycheck
Hit, shove, kick, strangle or use other forms of physical violence
Forbid or limit time with friends or family
Threaten to harm pets
Steal or destroy belongings
Force or coerce unwanted sex
Constantly criticize
Deny access to food, clothing or medical care
Threaten to hurt with or without weapons
Threaten to have deported or disclose sexual orientation
Threaten to take children
Threaten suicide if left
Expectations and Interests
In your own words, why did you come in for services today?
What do you expect to gain from your experience with JF&CS?
Is there anything in your life about which you feel especially proud? Explain:
What are your dreams or goals for your life?
Please describe a time in your life when you were happiest.
Have you ever been physically, sexually or emotionally abused by your partner, or anyone else in your life even once? If so, please explain:
Have you ever physically, sexually or emotionally abused your partner, or anyone else in your life even once? If so, please explain:
Is there anything else about you that you think is important for me to know?
Were you referred by another clinician?
If yes, would you like for us to communicate with one another?
Yes, name of clinician:   No  
Client Signature
Signer Type:  
  Client (Please click "Sign with Touch" and oversee / assist the Client in signing.)
  Other (Please enter the Name of the signer below and indicate relationship with the Client then click "Sign with Touch" and oversee / assist the signing. For example: Jane Doe, mother)
   
Name:
 
Sign with Touch
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