Client Information:

Current Name:                                                Pronouns:

Date of Birth:                                                Current Age:

Name on Insurance:                                         Other Names Used:

Primary Language:                 Secondary Language:                        Preferred Language:

Cultural Identity/Tribe:

Religious/Spiritual Affiliation:

Home Address:

Primary Phone:                                        Secondary Phone:                        

Email:

May we leaves messages on your phone or email? (appointment reminders, office closures, invoices, etc):  Yes                No

Emergency Contact:

        Name:

        Phone:

        Relationship:

Employer:                                                Employer Address:

School (current or last attended):

        Grade:

Prescribing Doctor Name:                                Primary Care Doctor:

Phone:                                                        Phone:

Address:                                                Address:

Consent for Dr. Glasgow to contact them:  Yes   No

How will you pay for session?

        ___Out of Pocket [Cash/Credit Card] *Fee is to be set prior to first session, otherwise full session fee applicable at time of session

        ___Insurance

                If so, please complete the following information:

                Insurance Company

                Claims Address

                Claim Phone number:

                Copay Listed on Card:

                ID:        

                Group:

                Are you the holder of the insurance plan?

        If you are not the holder, please give the NAME, DATE OF BIRTH, and

ADDRESS of the insurance plan holder:

Your fee per sessions is $_________

Living Situation (circle all that apply):

Housing Adequate                                                 Incarcerated                        

Housing Overcrowded                                         Homeless                

Housing Dangerous                                                Dependent

Ward of State/Tribal Court                                        At-risk homeless

Degree of comfort in your living situation (1 uncomfortable -- 10 extremely comfortable):

List the members of your household (include pets):

Name                                        Age                                         Relationship

 

Reason for Treatment:

Briefly describe why you are seeking treatment at this time (include any symptoms of body, mind, or soul)

How long have you been experiencing these symptoms?

How and in what areas of your life do these symptoms get in the way?

What brings on the current symptoms?

What relieves these symptoms?

What other therapies or remedies have you tried?  

What outcome do you desire from therapy services now?

Resources:

List the external supports for your well-being (people, animals, plants, places, activities, things)

List the internal supports for your well-being(your attitudes/beliefs, feelings, sensations, skills/capabilities)

Means of stress relief

Do you engage in movement? How often?  What kind?

History:

Family History:

Does anyone in your family have (Check all that apply & name relationship of member with diagnosis):

Substance Use:

Substance Use (indicate if current or past; dose; treatment)

Ever injected drugs?                Yes                        No                If yes, which one?

Drug of Choice?

Longest period of sobriety?

Triggers to use:

Legal Involvement:

Past or Current:

Physical Functioning:

Allergies (Medication & Other):

Current Medical Conditions:

Current Medications (include herbs, vitamins, and over-the-counter with dose):

Past Medications:

Past Medical History (including hospitalizations/residential treatment, inpatient/outpatient, foster care, aftercare, intensive outpatient, groups)

Dates                        Inpt/Outpt                        Location                        Reason

Surgeries?:

Pain Management:

Nutrition:

Current Weight:                        Current Height:                        BMI:

Appetite (circle):        Good                                Fair                        Poor (please explain):

Social:

Supportive Social Network? (circle all that apply; Rate 1 weak -5 strong)

Finances:

No current problems                                        Financial Difficulties

Large indebtedness                                         Poverty/Near poverty

Impulsive Spending                                         Relationship Conflict over Finances

Check the Life Experiences that apply to you (indicate hx for events occurring 3 months or more):

Functional Assessment:

Are you able to care for yourself?

Assistive Devices Needed:

Psychological:

History of Depressed mood:                        Yes                                No

History of Suicidal ideation?

History of Suicidal Attempts:

Sleep Pattern:                # hours per day                        Time of onset sleep

Normal                        Sleeping too much                        Sleeping too little

Ability to concentrate:                Normal                        Difficulty concentrating

Energy Level:                Low                        Average/Normal                High

Bereavement/Loss:

List significant losses, deaths, abandonment, or traumatic incidents:

Do you practice traditions, spirituality, or religion?

How do you describe your spirituality?

Anything Else Important to Know:

Availability for Treatment:                                                                                                

List all available times each day beginning with first available time.  Appointments are scheduled on the hour.  Please visit the website to see current hours of operation.

A.M.                                         P.M.

Monday

 

Tuesday

 

Wednesday

 

Thursday

 

Friday

 

Saturday

Authorizations and Consent

By signing below, you agree that you have read, understood, and have access to digital copies of the documents below and agree to comply with updates during the duration of your treatment:

1.Acknowledgement of Receipt of the HIPAA:

_________________________________________________________                        ______

Print and Sign                                                                                Date

2.   Acknowledgement of Receipt of the Procedures and Policy:

_________________________________________________________                        ______

Print and Sign                                                                                Date

3.  Acknowledgement of Receipt of the Consent Agreement:

_________________________________________________________                        ______

Print and Sign                                                                                Date