Client History Packet for Adult
Please complete the following form. Your responses will be viewed by your clinician.
Email address *
Date *
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Time *
Time
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Who is completing this document? *
Required
Client's Name *
Date of Birth *
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Gender *
How did you hear about Theraplace? *
Name of Primary Care Physician and Clinic *
Do you give permission for ongoing regular updates to be provided to your Primary Care Physician? *
Primary reason(s) for seeking services *
Highest Level of Education *
Employment Status *
Required
Additional Information Relating to Education or Employment (area of study, job title, employer, etc.) *
Living Situation - Please choose all that apply. *
Required
With whom do you live? List people and pets if applicable. *
How important are spiritual or religious beliefs to you? *
Are you affiliated with a spiritual or religious group? If yes, which one? Type "no" if you are not affiliated with a spiritual or religious group. *
Would you like spiritual or religious beliefs incorporated into counseling? *
To which cultural or ethnic group do you belong? *
Are you experiencing any problems due to culture or ethnicity? If yes, please describe. Type "no" if you are not experiencing any problems due to culture or ethnicity. *
Other cultural/ethnic information:
Describe areas of interest or hobbies (ex. reading, crafts, physical fitness, outdoor activities, walking, travelling, volunteering). *
Describe your strengths and resources. What do you do well? Who do you consider supportive (pet, family, friend, therapist)? Which areas of your life are stable? *
Medical/Physical Health - Please check all that apply. *
Required
Please describe any recent changes in your physical health. Type "none" if no recent changes have occurred. *
Do you exercise? If yes, please describe what kind of exercise, how many days per week and how much time each day. Type "no" if you do not exercise. *
When your mother was pregnant with you, were there any complications during the pregnancy or birth? If yes, please explain. Type "no" if there were no complications. *
Please describe your family medical history (ex. history of cancer, diabetes, high blood pressure, etc.). *
Please list currently prescribed medication, including name of prescribing physician. Indicate if you experience any side effects from currently prescribed medication. Type "none" if you are not currently prescribed medication. *
Please list any current over-the-counter medication (ie. medication that does not require a prescription from a physician), including vitamins or herbal supplements. Indicate if you experienced any side effects from prescribed medication. Type "none" if you are not taking over-the-counter medication. *
Please list past prescribed medication, including name of prescribing physician. Indicate if you experienced any side effects from prescribed medication. Type "none" if you have not been prescribed medication. *
Are you allergic to medication or drugs? If yes, please describe. Type "no" if you have no allergies to medication or drugs. *
Are you involved in any active legal cases (ex. traffic, civil, criminal? If yes, please describe. Indicate charges and court hearing/trial dates. Type "no" if you are not involved in any active legal cases. *
Are you currently on parole? If yes, please list name of parole officer and monitoring county. Type "no" if you are not currently on parole. *
Please describe any other legal information you would like your clinican to know (ex. I will be returning to court to address custody of my child).
Do you have military experince? If yes, please describe (ex. branch of military, date enlisted, date discharged, type of discharge, rank at discharge). Type "no" if you have no current or past military experience. *
Chemical Use History - Check any that you have used in the past or currently use.
Used within past 7 days
Used within past 30 days
Used within past 90 days
Used within past 6 months
Used within past year
Used within past 5 years
Used in past, more than 5 years ago
Alcohol
Barbiturates
Cocaine
Ecstasy
Heroin
LSD or Hallucinogens
Marijuana
Methadone
Methamphetamine
Pain killers (not as prescribed)
Stimulants (pills)
Tranquilizer/sleeping pills
Other
How many caffeinated beverages do you drink per day? *
Have you ever smoked cigarettes? If Yes, please answer the following questions. If No, please skip to the next required questions. *
Do you currently smoke cigarettes? If yes, how many packs per day on average? How many years?
If you do not currently smoke cigarettes, how many years ago did you smoke? When did you quit? How did you quit?
Have you ever been treated for alcohol or drug use or abuse? If yes, for which substances, where were you treated, and when? Type "no" if you have never been treated for alcohol or drug use. *
CAGE AID - Question 1 of 4 - In the last three months, have you felt you should cut down or stop drinking or using drugs? *
CAGE AID - Question 2 of 4 - In the last three months, has anyone annoyed you or gotten on your nerves by telling you to cut down or stop drinking or using drugs? *
CAGE AID - Question 3 of 4 - In the last three months, have you felt guilty or bad about how much you drink or use drugs? *
CAGE AID - Question 4 of 4 - In the last three months, have you been waking up wanting to have an alcoholic drink or use drugs? *
Does anyone in your family have past or present substance use? If yes, please indicate which substance(s) and the family member's relationship to you. Type "no" if no family members have a history of substance use. *
Childhood/Adolescent Maltreatment or Abuse - Please check all that apply: *
Required
Childhood Development *
Developmental milestones met
Developmental delay
Social/Emotional
Cognitive (learning/thinking/problem-solving)
Language/Communication
Movement/Physical
Childhood Maltreatment or Abuse - Additional information you would like your clinician to know.
Please list immediate family members, including whether they are living or deceased, and approximate ages (ex. parent, sibling, step parent, grandparent, child, spouse, significant other). *
Any additional information about your family background you would like to share (ex. adopted, moved a lot, happy childhood, turbulent childhood, split household, lived in the city, lived in a rural area, raised by grandparents, mother's occupation)?
Parental Information - Please check all that apply. *
Required
Relationship Status - Please check all that apply. *
Required
Children in home *
Required
Sexual orientation *
Required
Adult Trauma History - Please check all that apply. *
Required
Do you have a history of being a sexual predator? *
Current Symptoms - Please check any behaviors and symptoms that you experience. *
Required
Briefly discuss how the above symptoms affect your functioning at home, school, work, in the community or socially. *
History of symptoms. Please describe when your symptoms started, when they worsen or improve, etc. *
Symptom Scaling Questionnaire - Circle one number between 0 and 10 to describe each category. *
0 (none)
1
2
3
4
5
6
7
8
9
10 (Severe)
Sadness
Suicidal thoughts
Anxiety
Frustration/anger