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Accompanied By:
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Relationship:
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SPECIFIC PRESENT CONCERNS:
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Depression
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Do You:
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Do You Have:
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Staff Use Only:
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Suicidality:
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Have you become obviously withdrawn/isolated?
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Are you having suicidal thoughts?
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Is there a plan?
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Is there a means to carry out this plan?
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What has or what could prevent you from acting on plan?
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Any suicidal thoughts in the past?
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if yes, what did you do?
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Have you ever heard voices telling you to harm yourself?
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Have you ever injured yourself on purpose?
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Have you had any suicidal attempts or actual suicides by family or friends?
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Please specify:
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Behaviors:
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Are you overly aggressive/destructive/argumentative or defiant?
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List any injuries to self or others that resulted from above behavior:
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Any thought/threats/plans to harm others?
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If yes, describe frequency and intensity of the thoughts:
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Is there any plan/means to carry out plan?
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If yes, who is the individual(s) at risk?
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Have you made any verbal threats to anyone in the past 2 weeks?
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If yes, please describe:
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Have you ever repeated threats to someone?
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Do you have any difficulty with hyperactivity/impulsivity or paying attention?
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Cognitive:
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Are you experiencing thoughts that:
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Are You:
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Anxiety:
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Are you:
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Trauma Symptoms:
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Have you witnessed or experienced a traumatic event (including emotional, physical or sexual abuse)?
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If yes, please explain:
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If yes, have any of the following been experienced/exhibited:
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Eating History:
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Are you:
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Sleep:
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Are you:
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Time it takes to fall asleep:
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How many hours of sleep in a 24-hour period:
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Aids used to promote sleep:
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Duration of problems:
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Addictive Symptoms:
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Have you ever used alcohol or drugs?
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If yes, please describe:
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If yes, have you ever:
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How often have you had a drink upon awakening?
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Family Mental Health:
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Have any of your relatives been treated for or taken medicine for mental health or nervous disorder?
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Please identify family members relationship to yourself:
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Check any illnesses that apply:
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If possible, please explain:
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Legal:
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Have you had any charges or legal offenses (DUI, DWI, PI, felonies/misdemeanors)?
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If yes, please specify:
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Have you had any violent offenses?
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If yes, please specify:
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Any legal charges pending?
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If yes, please specify:
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Is treatment a result of your legal problems?
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If yes, please specify:
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Any lawsuits, divorces or custody issues in process or being initiated?
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If yes, please specify:
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Past Treatment History:
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Have you had psychiatric/substance abuse treatment in the past?
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If yes, what kind?
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What were you treated for?
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Dates of Treatment and Clinic/Facility/Clinician:
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Did you follow up with treatment recommendations?
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If no, explain why:
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Were any medications prescribed?
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If yes, list:
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Have you had previous evaluations (psychological, educational, neurological)?
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If yes, specify date and type:
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Was treatment helpful?
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Was family therapy included in treatment?
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Was group therapy included in treatment?
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Do you feel you fully participated in treatment?
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Housing:
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Are you:
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Are you living with:
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Name/Relationship of people living with you:
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Names/Ages of children living with you:
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Family of Origin:
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Birth Order:
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Number of Siblings:
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Were your parents:
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Did your family move frequently?
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If divorced, did your mother remarry or have live-in partner?
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If yes, please specify:
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If divorced, did your father remarry or have live-in partner?
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If yes, please specify:
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Raised by [check the most significant person(s)]:
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If not raised by biological parents, state why:
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How did female caregiver punish you when you did something wrong?
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How did male caregiver punish you when you did something wrong?
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Education:
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Highest Level Completed:
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Difficulty with reading/writing?
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Average grades received in high school:
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How do you learn best?
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Positive relationship with classmates in school?
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Positive relationship with authority figures in school?
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Any drug or alcohol use at the time?
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If yes, specify type, amount and frequency:
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Work:
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Are you:
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If employed, what type of work are you doing?
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Do you enjoy your job?
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Are you currently looking for a new job?
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Does household income pay for basic necessities?
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If not working currently, what type of work was done in the past
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Military:
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Current/Previous service in the U.S. Military?
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If yes, type of discharge:
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Any trauma related to service?
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If yes, please explain:
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Marital:
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Are you:
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If married, but separated, for how long?
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If divorced or annulled, for how long?
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Are you in a new dating relationship?
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If yes, are you:
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If married more than once, specify number and length of previous marriages:
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Are you happy in your current relationship?
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Are there any problems in your current relationship?
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If yes, please explain:
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Stressors/Support System:
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Have you experienced significant events within the past year (death, job loss, etc.)?
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If yes, please specify:
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Have you experienced abuse, neglect or violence?
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If yes, please specify:
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Please list any events past one year ago that have had a negative impact on your life:
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Who do you rely on for support?
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What has helped you through difficult times in the past?
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Who do you spend free time with?
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Are there any activities you used to do that you would like to do again?
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If yes, please specify:
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Developmental History:
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Did physical maturity occur around the same age as most peers?
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Age you began to date:
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Did parents object to the individual(s) dated?
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Age of first sexual experience:
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Sexual Preference:
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Please specify:
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Any legal problems growing up?
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Any running away growing up?
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Any major health problems while growing up?
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If yes, please specify:
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Growing up, were you:
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Cultural / Spiritual:
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Religious Preference:
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Importance of faith during treatment:
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Religious considerations:
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Cultural considerations:
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Medical considerations:
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Discharge:
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Is there anything else you would like us to know?
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How will you know you have met your goals?
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