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The following form will become part of your confidential record.
Please answer the following questions as carefully as you can. There
will be space provided for any additional comments.
Date:Name:
DOB: Age:
Present address:
Telephone:(Home)
(Work)
SSN:
Beeper/ Cell Phone:
Person to contact in case of emergency:
Address:
Telephone:
Marital Status: If married how many years?
If separated/divorced, for how long:
Number of Marriages:
Living with:
Occupation:
Hours Per Week?
Employer:
Highest level of education completed:
Major:
Religious Affiliation:
Number of times you attend religious per month:
Explain your Spiritual Beliefs:
Name of Primary Care Physician:
Are you currently receiving medical treatment?
Describe any physical problems you have that require medication or
physical care:
List prescription or non prescription drugs you are now taking
including herbal remedies and over the counter medicines:
Have you previously had counseling/ therapy? When?
With Whom?
For how long?Why
did you stop?
Family Members
Spouse:
Children:
Father:
Mother:
Others:
Problem Areas: In the following list, please place a check mark next
to each item which indicates an area of concern to you. Place two checks
by the items which are most important (you may add comments).
Anxiety
Depressed
Mood
Guilt
feelings
Under
activity
Weight
loss
Headaches
Feelings
of inferiority
Loss
of interest
Poor
sleeping
Repetitive
ideas
Thoughts
of suicide
Wish
to hurt others
Marital
relationship
Financial
problems
Lonely/
too few friends
Unhappy
most of the time
Problem
with children
Troubling
memories
Inability
to relax
Memory
difficulties
Lack
of confidence
Can't
make decisions
Bitterness
or resentment
Periods
of Over activity
Eating
Problems
Shy
or Awkward with others
Unable
to trust others
Change
in eating habits
Fighting/
arguing with others
Can't
stand up for myself
Can't
say "no" to others
Poor
adjustment to job/school
Bad
temper/ anger problems
Difficulties
with opposite sex
Stomach
or bowel disturbance
Unfairly
treated by others
Drinking
or drug problems
Rely
too much on others
Suspicious
of others
Recent
loss of someone
Sexual
problems/ concerns
Family
quarreling
Fearful
of things or situations
Religious/
spiritual concerns
Cardiovascular/
heart problems
Alcohol/
drug problem in family
Unusual/
strange experiences
Stress
from recent event
Divorce/
separation difficulty
Troubling
habits/ thoughts
Feeling
rejected by family Weight
gain
Over
activity
Repetitive
behaviors
Other (specify)
Do you use or have you in the past used any of the following? (How
much? How often? How long?)
Cigarettes:
Alcohol:
Other Substances:
List any family history or alcohol or drug use:
List any family history of mental illnesses:
List any drug or food allergies you may have:
In your own words, briefly describe the main problem(s) which
prompted you to seek counseling at this time:
Have there been times when the problem(s) got better or disappeared?
If so, when?
What do you think helped?
Were there times when the problem was especially bad?
If so, when?
What made it bad?
Are there other people who play a role in causing your problem?
Helping your problem?
Explain briefly:
Name the main goal that you would like to reach in counseling:
How did you hear about Barnabas Healthcare?
If another professional or a pastor referred you can we thank them
and notify them that we will be working together without disclosing any
further information?
Name:
Address:
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