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Ottagan Addictions Recovery
483 Century Lane
Holland, Michigan 49423
Phone 616-396-5284
Fax 616-396-8387
 Client Information
  First Name:  * Last Name:  *  
           
  Date of Birth:  * Gender:  *  
    (Format: mm/dd/yyyy)      
  Address: City:  
  State: Zip Code :  
  Phone No:  
Please mark an X beside each statement that applies.
X means "Yes, I have experienced..."

Blank means "No, I have not..."
Have you ever experienced any of the following? If yes, mark with X. If no, leave blank.
  In the last year? (Recent History) Before this last year? (Long term History)
Excessive use of alcohol
Excessive use of other drugs
Problems with relationships
Problems at work
Legal problems
Depressed mood (feeling depressed)
Difficulty having fun
Irritability/anger problems
Assaultive behavior
Restlessness/can't sit still and difficulty sleeping
Nervous/tense
Panic attacks/anxiety
Difficulty concentrating
Thoughts of harming self
Thoughts of harming others
Feeling inferior/hopelessness
Overly sensitive
Overwhelmed/worried
Feeling lonely
Feeling guilty
Sexuality issues
Fears or phobias
Other (please list in space below)
List symptoms if you checked "Other" above:
What would you like to change about yourself with the support of counseling?
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