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Anger Management ASB Intake Form
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* Indicates required question
Email
*
Your email
Client Name
*
Your answer
Date of Birth (dd/mm/yyyy)
*
Your answer
Sex
*
Female
Male
Prefer not to say
Other:
Marital Status
*
Married
Single
Other:
What is the presenting problem?
*
Your answer
How long have you had issues around anger?
*
Your answer
Have you had experience with past counseling?
*
Yes
No
If yes, when was the last time? And for how long?
Your answer
Please list any medical conditions and and medication you take.
*
Your answer
Do you take steroids?
*
Yes
No
Do you take Testosterone?
*
Yes
No
Are you experiencing financial problems?
*
Yes
No
Are you experiencing any legal problems?
*
Yes
No
Was this court mandated?
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Yes
No
Do you have troubles at work stemmed from your anger?
*
Yes
No
If yes, please explain.
Your answer
Who do you have as your support system (i.e. family and friends)?
Your answer
Did you witness violence in your home as a child?
Yes
No
Clear selection
If yes, please describe.
Your answer
Are you or have you even been involved in a gang?
Yes
No
Prefer not to say
Clear selection
Are you in a relationship with someone who has a problem with alcohol or drug?
Yes
No
Clear selection
B. Psychological Information
How would you rate your level of energy?
Low
Regular
High
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Do you experience any sleep disturbance?
Yes
No
Clear selection
If yes, please check all that apply.
Difficulty falling asleep
Waking up too early and not being able to go back to sleep.
Sleeping too much- over 8-9 hours daily.
Not being able to sleep for more than 3 hours per night for a few nights consecutively.
Have you experienced any appetite changes in the past two weeks?
Yes
No
Clear selection
If yes, please check one that applies.
Increase in appetite
Decrease in appetite
Clear selection
Do you find yourself getting easily irritated?
Yes
No
Clear selection
How would you rate your self esteem?
Low
Medium
High
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Do you experience feelings of hopelessness?
Yes
No
Clear selection
Do you experience feelings of helplessness?
Yes
No
Clear selection
Do you have psychiatric problems?
Yes
Clear selection
If yes, please describe.
Your answer
Are you a danger to yourself now?
Yes
No
Clear selection
Have you ever attempted suicide?
Yes
No
Clear selection
Ever hospitalized?
Yes
No
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If so, when?
Your answer
Do you have a history of violent behavior?
Yes
No
Clear selection
If yes, please describe your recent violent behaviors.
Your answer
Is there a family history of Suicide?
Yes
No
Clear selection
If yes, please explain.
Your answer
Is there a family history of Depression?
Yes
No
Clear selection
If yes, please explain.
Your answer
Is there a family history of Violence?
Yes
No
Clear selection
If yes, please explain.
Your answer
Do you go on uncontrollable shopping sprees?
Yes
No
Clear selection
Do you gamble?
Yes
No
Clear selection
If yes, how often?
Your answer
Do you have obsessions or compulsions?
Yes
No
Clear selection
If yes, please describe.
Your answer
Domestic Violence
Are you in a relationship?
Yes
No
Clear selection
If yes, for how long?
Your answer
Are you married?
Yes
No
Clear selection
If yes, are you living with your significant other?
Yes
No
Clear selection
If yes how long did you date before moving in or getting married?
Your answer
Have you ever hit your partner?
Yes
No
Clear selection
Have you ever broken anything, or punched walls in their presence?
Yes
No
Clear selection
Is there any name calling?
Yes
No
Clear selection
If yes, what kind of names?
Your answer
Any threats, such as "If you ever leave me, I'm going to kill you."
Yes
No
Clear selection
Any put downs, such as "If you leave me, no one else would take you."
Yes
No
Clear selection
Do you make promises after blow ups, such as promising to get help?
Yes
No
Clear selection
Do you get along with your partner's family and/or friends?
Yes
No
Clear selection
Substance Abuse Screening
What types/frequency of drugs (including prescription) and alcohol have you used?
Your answer
Do you think of yourself as a "normal" drinker?
Yes
No
Clear selection
Have you ever had memory problems following a night of drinking?
Yes
No
Clear selection
Does any member of your family ever worry or complain about your drinking or drug use?
Yes
No
Clear selection
Are you able to stop drinking or using when you want?
Yes
No
Clear selection
Have you ever attended an AA meeting or other 12 step or drug/alcohol treatment program?
Yes
No
Clear selection
If yes, which ones?
Option 1
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Has drinking or drug use ever created problems between you and your partner or other family members?
Yes
No
Clear selection
Have you ever missed work or other obligations because of drinking?
Yes
No
Clear selection
Is there a family history of alcohol or drug problems?
Yes
No
Clear selection
If yes, please explain.
Your answer
A copy of your responses will be emailed to the address you provided.
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