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Social Security Number: | |
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Drivers License Number: | |
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Address & Phone: |
Address: | | Address Line 2: | | City: | | State: | | Zip Code: | | Phone: | (Home) | | (Business) | | (Cell) | | Message may be left at above phone number? | | | | Yes No | | Yes No | | Yes No | Email: | | |
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Emergency Contact: |
Name: | | Address: | | Address Line 2: | | City: | | State: | | Zip Code: | | Phone: | (Home) | | (Business) | | (Cell) | Relationship: | | Email: | | |
I. ADULT CLIENT
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Concerns for which you are seeking assistance |
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II. FAMILY INFORMATION
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A. Marital status |
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B. Race/cultural information
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Race | |
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Cultural considerations | |
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LGBTQ Considerations: | |
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C. Family history of mental health or substance abuse problems | |
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Explain |
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D. Your parents marital status is |
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Your parents are |
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Father's name | |
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Father's age | |
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If father deceased, date | |
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Father's occupation | |
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Father's highest grade level | |
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Mother's name | |
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Mother's age | |
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If mother deceased, date | |
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Mother's occupation | |
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Mother's highest grade level | |
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E. Your annual family income |
| Under $30,000 | | $31,000 - $60,000 | | $61,000 - $90,000 | | $91,000 - $120,000 | | $121,000 - $150,000 | | Over $151,000 | |
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F. Language spoken | |
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G. Current family size | |
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H. Your brothers and sisters |
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I. Your children |
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J. Spouse and/or Other household members |
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K. Relationships
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1. Who do you live with currently? | |
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2. Who did you grow up with? | |
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3a. Describe your relationship with your parents | |
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3b. Describe your relationship with your siblings | |
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3c. Describe your relationship with your extended family members | |
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3d. Describe your relationship with your spouse/significant other | |
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3e. Describe your relationship with your children | |
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4. List any family members you wish to have involved in treatment and why | |
III. PHYSICAL DESCRIPTION
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A. Height | |
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Weight | |
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Recent gains or losses | |
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B. Other distinguishing features | |
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C. List any physical impairments or disabilities | |
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D. Explain any physical characteristics or body image concerns | |
IV. EDUCATION
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A. Graduated high school | |
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Year | |
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Graduated GED | |
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Year | |
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B. Did not complete school | |
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If yes, last school attended | |
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Grade completed | |
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C. Currently enrolled | |
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If yes, last grade completed | |
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Current grade | |
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D. Post high school education | |
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Explain | |
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E. Years in special education | |
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Special education certification | |
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F. School performance is/was a concern | |
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Explain | |
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G. READING LEVEL: |
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V. EMPLOYMENT
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A. Currently employed | |
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If yes, indicate |
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B. Name of employer | |
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C. Position | |
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D. List type of jobs held over last five years | |
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E. Describe your level of satisfaction with your employment/career | |
VI. SPIRITUAL INFORMATION
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A. Spirituality is an area of support or strength | |
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Religion |
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Other | |
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B. Is this an area of concern? | |
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If yes, explain | |
VII. SEXUAL FUNCTIONING
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Is this an area of concern? | |
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If yes, explain | |
VIII. COMMUNITY SERVICES RECEIVED
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A. Mental health counseling/substance abuse treatment
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Previous counseling where | |
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Previous counseling when | |
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Previous counseling where | |
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Previous counseling when | |
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Previous counseling where | |
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Previous counseling when | |
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Was counseling helpful to you in the past? | |
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If yes, explain | |
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B. Support groups
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1. List any support groups you attended in the past or present | |
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2. Was support group attendance helpful? | |
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If yes, explain | |
IX. SUBSTANCE ABUSE
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A. Do you use illegal or unprescribed drugs including alcohol? | |
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If yes, explain which drugs, amount and frequency | |
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B. Do you misuse prescription dugs? | |
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If yes, explain which drugs and how they are misused | |
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C. Do you drink alcohol? | |
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If yes, describe amount and how often per week | |
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D. Is drug or alcohol use an area of concern? | |
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If yes, explain | |
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E. Has anyone ever expressed concern with your use of alcohol or other drugs? | |
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If yes, explain | |
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F. Have you ever been to an Alcoholics Anonymous or Narcotics Anonymous meeting? | |
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G. Have you ever had a legal charge related to alcohol or other drug use? | |
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If yes, explain | |
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H. Do you smoke cigarettes? | |
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If yes, explain time period, amount and frequency | |
X. SOCIAL LIFE
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A. Explain your family's strengths | |
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B. Describe your support system (i.e., family, friends) | |
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C. Describe your recreational interests | |
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D. Describe any relationship problems with friends/coworkers | |
XI. HEALTH HISTORY
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A. Primary physician | |
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Primary physician address | |
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Primary physician phone | |
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Date of last physical exam | |
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B. Pharmacy (include Street, City): | |
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Phone: | |
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C. List all current prescriptions, regularly taken, over the counter meds and supplements | |
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D. Any concerns about medications, including drug allergies? | |
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If yes, explain | |
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E. Health problems |
| Status | Family History | | Allergies | | | Anorexia | | | Asthma | | | Broken Bones | | | Communicable Diseases | | | Diabetes | | | Fainting/Dizzy | | | Hearing Problems | | | Heart Disease | | | High/Low Blood Pressure | | | High/Low Blood Sugar | | | Liver Disease, Jaundice | | | Major Injuries | | | OB/Gyn Problems | | | Obesity | | | Seizures/Epilepsy | | | Stomach or Intestinal Problems | | | Thyroid Problems | | | Ulcer | | | Vision Problems | | | |
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High/low blood sugar |
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Comments |
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Assistive Technology Needed: | |
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F. Nutrition generally good? | |
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Explain any special dietary needs/concerns | |
XII. ABUSE HISTORY
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Have you (or your child) experienced or witnessed physical , sexual or emotional abuse or trauma? | |
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If yes, explain | |
XIII. LEGAL HISTORY
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A. Any history of legal charges? | |
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If yes, explain | |
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B. Are you currently on parole? | |
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If yes, explain | |
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C. Is treatment court ordered? | |
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If yes, explain | |
XIV. ANY OTHER RELEVANT CONCERNS
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Please describe |
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Notes |
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Form Updates |
Name |
Date |
Action |
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Form Started
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