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People to People
1200 E. Wheeling Ave.
Phone 740-432-1800
 Client Information
  First Name:  * Last Name:  *  
           
  Date of Birth:  * Birth Sex: 
* 
         
  Address: City:  
  State: Zip Code :  
  Phone No:  
Date
How did you hear about us?
Presenting Problem    Why are you seeking services?
Other areas of concerns:    i.e housing, employment, disability application, job training, time/money management, applying skills outside of session, relationships, public assistance needs, school/grades, living skills, transportation
How do you know it is a problem?    Frequency of symptoms
Maintenance of problem    What have you done or are doing to deal with this problem?
What do you want to get out of therapy?
Have you ever wished you were dead or wished you could go to sleep and not wake up?
Problem Checklist    Check All that Apply
  Yes/No How often do you have this problem? How long have you had this problem? Comments
Addiction (Drugs & Alcohol)
Addiction (Gambling/Porn/Sex)
Anger/Aggression
Anxiety
Panic Attacks
Depression
Flashbacks
Grief
Guilt
Hopelessness
Hyperactivity/ADD
Inattention/Easily Distracted
Impulsive
Irritability
Low Self Esteem
Mood Swings
BiPolar
Oppositional Behaviors
Paranoia
reckless, risk taking or self-destructive behaviors
Schizophrenia
Traumatic Stress (Past or Current)
Discrimination due to race, ethnicity, and/or LGBTQ+ status
Food insecurity (problems with having enough to eat)
Housing insecurity/issues
Transportation issues/lack of transportation
Employment issues
Any repetitive thoughts, images, or impulses that you can't get out of your mind?
DO YOU THINK ABOUT ANYTHING REPEATEDLY THAT CAUSES ANXIETY?
Do you engage in any repetitive or ritualized behaviors ?
Do you feel like any of these behaviors don't make sense or take up more time than is necessary?
Nutrition/Eating Problems
Do you make yourself Sick because you feel uncomfortably full?
Do you worry you have lost Control over how much you eat?
Have you recently lost more than 14 lbs in a 3month period?
Do you believe yourself to be Fat when others say you are too thin?
Would you say Food dominates your life?
Prior Mental Health/AoD Treatment
Past responses to treatment both positive and negative:    Reason? Focus? Type of therapy? Length? Why did you stop? Results? What did you learn that was helpful? Anything not addressed? Likes and dislikes of prior therapy?
Previous or Current Diagnosis
List current medications (prescriptions, over the counter, herbals, vitamin/mineral/dietary supplements) including name, dosages, frequency and route.
Past Psychiatric Medications    Please list medication and reason it was stopped
Medical Problems
Primary Care Physician
Medical Problem Checklist    Check All that Apply
  Yes/No How long have you had this?
Diabetes
Headaches
Nausea or abdominal distress
LOW OR DECREASED ENERGY/FATIGUE
Fibromayalgia/Muscle Pain
CHRONIC PHYSICAL PAIN
Cardiac or respiratory problems (i.e. asthma, emphysema, high blood pressure, heart attack/angina)
Epilepsy/Seizures
Hepatitis/Jaundice
Tuberculosis
AIDS/HIV
Gastric Bypass Surgery
Dental Health Concerns
Visual Health Concerns
Hearing Concerns
Allergies
Gastrointestinal/hepatic problems (i.e. liver disease, pancreatitis, gastric ulcer, reflux)
Physical injuries or problems (i.e. back injury, limb fracture or injury)
Neurological problems (i.e. fits, seizures, epilepsy, migraines)
Skin conditions
Pregnancy
Sleep Problems
Is there any other information regarding your medical history that we should know about?
Family history of any medical conditions and clients relationship to that family member.
Tobacco Use
Are you interested in stopping smoking?
Has client had any of the following symptoms in the past 60 days?
Ankle Swelling   Bedwetting   Blood in Stool  
Breathing Difficulty   Chest Pain   Confusion  
Consciousness Loss   Constipation   Coughing  
Cramps   Diarrhea   Dizziness  
Falling   Gait Unsteadiness   Hair Change  
Hearing Loss   Lightheadedness   Memory Problems  
Mole/Wart Changes   Muscle Weakness   Nervousness  
Nose Bleeds   Numbness   Panic Attacks  
Penile Discharge   Seizures   Shakiness  
Sleep problems   Sweats (nights)   Tingling in Arms & Legs  
Tremors   Urination Difficulty   Vaginal Discharge  
Vision Changes   Vomiting   Other  
Allergies    Allergies to food, medicine (Medication allergies or adverse reactions to medications, etc.
In your lifetime, have you ever been hospitalized or treated in an emergency room following an injury to your head or neck? Think about any childhood injuries you remember or were told about.
Do you participate in any sports, exercise programs or activities on a regular basis?
Yes   No    
What are your interests and things you do for fun?
Do you use complementary health approaches?    Ex's: natural products, such as dietary supplements, • Mind and body practices, such as acupuncture, massage therapy, meditation, movement therapies, yoga, and relaxation techniques. • Homeopathy, naturopathy, and traditional healers.
Pregnancy History
How many times have you been pregnant?
Currently pregnant? If no go to bottom and sign form
If yes, expected delivery date?
Receiving prenatal healthcare?
Prenatal healthcare provider?
Form Updates
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